Provider Demographics
NPI:1407860745
Name:PROVIDENCE SURGERY CENTER
Entity Type:Organization
Organization Name:PROVIDENCE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:HOWERY
Authorized Official - Last Name:SHOOSHTARI
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA
Authorized Official - Phone:406-327-3301
Mailing Address - Street 1:902 N ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2916
Mailing Address - Country:US
Mailing Address - Phone:406-327-3300
Mailing Address - Fax:406-327-3302
Practice Address - Street 1:902 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2916
Practice Address - Country:US
Practice Address - Phone:406-327-3300
Practice Address - Fax:406-327-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10708261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0350098Medicaid
MT000005699Medicare PIN