Provider Demographics
NPI:1477625721
Name:KIM HACKL ANESTHESIA INC
Entity Type:Organization
Organization Name:KIM HACKL ANESTHESIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:406-586-0802
Mailing Address - Street 1:3720 TRAIL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-1719
Mailing Address - Country:US
Mailing Address - Phone:406-586-0802
Mailing Address - Fax:
Practice Address - Street 1:300 N WILLSON AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3551
Practice Address - Country:US
Practice Address - Phone:406-586-1956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN20815367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4308106Medicaid