Provider Demographics
NPI:1154478618
Name:BEAVERHEAD EMERGENCY MEDICAL SERVICES
Entity Type:Organization
Organization Name:BEAVERHEAD EMERGENCY MEDICAL SERVICES
Other - Org Name:BEAVERHEAD EMS
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:406-683-2391
Mailing Address - Street 1:P.O. BOX 1106
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-1106
Mailing Address - Country:US
Mailing Address - Phone:406-683-2833
Mailing Address - Fax:406-683-2833
Practice Address - Street 1:330 E REEDER ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-2777
Practice Address - Country:US
Practice Address - Phone:406-683-2833
Practice Address - Fax:406-683-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT104341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT443352Medicaid
MTM000002338OtherMEDICARE ID - TYPE UNSPECIFIED
MTM000002338OtherMEDICARE ID - TYPE UNSPECIFIED
MTM000002338Medicare PIN
MT443352Medicaid