Provider Demographics
NPI:1275789901
Name:GLACIER ONCOLOGY, PLLC
Entity Type:Organization
Organization Name:GLACIER ONCOLOGY, PLLC
Other - Org Name:MICHAEL G GOODMAN, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-752-7600
Mailing Address - Street 1:75 CLAREMONT ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3585
Mailing Address - Country:US
Mailing Address - Phone:406-752-7600
Mailing Address - Fax:406-752-7614
Practice Address - Street 1:75 CLAREMONT ST
Practice Address - Street 2:SUITE E
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3585
Practice Address - Country:US
Practice Address - Phone:406-752-7600
Practice Address - Fax:406-752-7614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8025261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT830004450OtherRAILROAD MEDICARE
MT011071OtherBLUE CROSS BLUE SHIELD
MT0105825Medicaid
MT010001107Medicare PIN
MT830004450OtherRAILROAD MEDICARE