Provider Demographics
NPI:1407366545
Name:GLACIER DERMATOLOGY PC
Entity Type:Organization
Organization Name:GLACIER DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-314-6336
Mailing Address - Street 1:40 FOUR MILE DR STE 7
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2655
Mailing Address - Country:US
Mailing Address - Phone:406-314-6336
Mailing Address - Fax:
Practice Address - Street 1:40 FOUR MILE DR STE 7
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2655
Practice Address - Country:US
Practice Address - Phone:406-314-6336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10806207N00000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0143741Medicaid