Provider Demographics
NPI:1114973781
Name:GLACIER NEUROSCIENCE & SPINE LLC
Entity Type:Organization
Organization Name:GLACIER NEUROSCIENCE & SPINE LLC
Other - Org Name:GLACIER NEUROLOGICAL ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-752-5095
Mailing Address - Street 1:200 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1914
Mailing Address - Country:US
Mailing Address - Phone:406-752-5095
Mailing Address - Fax:406-752-5098
Practice Address - Street 1:200 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1914
Practice Address - Country:US
Practice Address - Phone:406-752-5095
Practice Address - Fax:406-752-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT84755Medicare PIN