Provider Demographics
NPI:1407215684
Name:BLACKFEET
Entity Type:Organization
Organization Name:BLACKFEET
Other - Org Name:TRIBAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:406-845-6284
Mailing Address - Street 1:1052 SUN DOWN RD
Mailing Address - Street 2:PO BOX 505
Mailing Address - City:BROWNING
Mailing Address - State:MT
Mailing Address - Zip Code:59417
Mailing Address - Country:US
Mailing Address - Phone:406-845-6284
Mailing Address - Fax:406-338-2491
Practice Address - Street 1:503 POPIMI STREET
Practice Address - Street 2:
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417
Practice Address - Country:US
Practice Address - Phone:406-338-4696
Practice Address - Fax:406-338-2491
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACKFEET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-17
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT=========Medicaid