Provider Demographics
NPI:1407301872
Name:KALISPELL REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:KALISPELL REGIONAL MEDICAL CENTER INC
Other - Org Name:GLACIER ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-1724
Mailing Address - Street 1:711 E 13TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2964
Mailing Address - Country:US
Mailing Address - Phone:406-862-5656
Mailing Address - Fax:406-862-6155
Practice Address - Street 1:711 E 13TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2964
Practice Address - Country:US
Practice Address - Phone:406-862-5656
Practice Address - Fax:406-862-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11198204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty