Provider Demographics
NPI:1235238718
Name:BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC
Entity Type:Organization
Organization Name:BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC
Other - Org Name:BLACKTAIL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BREANNA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:MATICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-496-6000
Mailing Address - Street 1:445 CENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2870
Mailing Address - Country:US
Mailing Address - Phone:406-723-4075
Mailing Address - Fax:406-496-6035
Practice Address - Street 1:125 E GLENDALE ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-2505
Practice Address - Country:US
Practice Address - Phone:406-683-4440
Practice Address - Fax:406-683-1121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QD0000X, 261QF0400X
MT261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT95601016OtherMT BREAST & CERVICAL PROG
MT63392OtherBCBS
MTCK5130OtherRAILROAD MEDICARE
MT0730028Medicaid
MT000008423Medicare ID - Type Unspecified
MO271817Medicare ID - Type Unspecified