Provider Demographics
NPI:1376637470
Name:MISSOULA COMMUNITY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:MISSOULA COMMUNITY HEALTH SERVICES, INC.
Other - Org Name:TAMARACK MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNEECE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-822-4841
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872
Mailing Address - Country:US
Mailing Address - Phone:406-822-4841
Mailing Address - Fax:406-822-4963
Practice Address - Street 1:1208 6TH AVE E
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872
Practice Address - Country:US
Practice Address - Phone:406-822-4841
Practice Address - Fax:406-822-4963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOULA COMMUNITY HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MT207Q00000X, 261QR1300X
MT11203261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT9989941OtherPASSPORT PROVIDER NUMBER
MT720460Medicaid
MT0000066882OtherBLUE CROSS BLUE SHEILD
MT9989941OtherPASSPORT PROVIDER NUMBER
MT000008398Medicare PIN
MT273403Medicare ID - Type UnspecifiedMEDICARE RURAL HEALTH CLI