Provider Demographics
NPI:1447244140
Name:FIELD OF DREAMS PC
Entity Type:Organization
Organization Name:FIELD OF DREAMS PC
Other - Org Name:BOZEMAN URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-586-8711
Mailing Address - Street 1:1006 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3219
Mailing Address - Country:US
Mailing Address - Phone:406-586-8711
Mailing Address - Fax:406-587-2602
Practice Address - Street 1:1006 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3219
Practice Address - Country:US
Practice Address - Phone:406-586-8711
Practice Address - Fax:406-587-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4048174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1139340001Medicare NSC
MT000080214Medicare ID - Type UnspecifiedGROUP NUMBER
MT010001104Medicare ID - Type UnspecifiedINDIVIDUAL ID
MTD96160Medicare UPIN