Provider Demographics
NPI:1407987548
Name:BLUE MOUNTAIN CLINIC, INC.
Entity Type:Organization
Organization Name:BLUE MOUNTAIN CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-721-1646
Mailing Address - Street 1:610 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3950
Mailing Address - Country:US
Mailing Address - Phone:406-721-1946
Mailing Address - Fax:406-543-9890
Practice Address - Street 1:610 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3950
Practice Address - Country:US
Practice Address - Phone:406-721-1946
Practice Address - Fax:406-543-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0218478Medicaid
MT0218478Medicaid