Provider Demographics
NPI:1417198243
Name:PROVIDENCE HEALTH & SERVICES MT
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:PMG MT WOMEN'S CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:BODLOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-543-7271
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-1918
Mailing Address - Fax:406-329-2937
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4096
Practice Address - Country:US
Practice Address - Phone:406-327-3057
Practice Address - Fax:406-327-3231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-06
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN