Provider Demographics
NPI:1407803232
Name:CHISDAK OB-GYN
Entity Type:Organization
Organization Name:CHISDAK OB-GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISDAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-556-4649
Mailing Address - Street 1:1648 ELLIS ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8810
Mailing Address - Country:US
Mailing Address - Phone:406-556-4649
Mailing Address - Fax:406-556-7083
Practice Address - Street 1:2132 BROADWATER AVE
Practice Address - Street 2:STE A1
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-4778
Practice Address - Country:US
Practice Address - Phone:406-556-4649
Practice Address - Fax:406-556-7083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9885207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT44285Medicaid
MT82404Medicare ID - Type Unspecified
H56051Medicare UPIN