Provider Demographics
NPI:1275560617
Name:POWELL COUNTY MEMORIAL HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:POWELL COUNTY MEMORIAL HOSPITAL ASSOCIATION INC
Other - Org Name:DEER LODGE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JAENA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-846-7717
Mailing Address - Street 1:1100 HOLLENBACK LANE
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722-1828
Mailing Address - Country:US
Mailing Address - Phone:406-846-2212
Mailing Address - Fax:406-846-3074
Practice Address - Street 1:1100 HOLLENBACK LANE
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-1828
Practice Address - Country:US
Practice Address - Phone:406-846-2212
Practice Address - Fax:406-846-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10408282NC0060X
MT9623314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0311701Medicaid
MT0411740Medicaid
MT3503227Medicaid
MT3100383Medicaid
MTG56347Medicare UPIN
MT0311701Medicaid
MT3100383Medicaid
MT0411740Medicaid
MT000009987Medicare PIN
MT3503227Medicaid
MT27Z314Medicare Oscar/Certification