Provider Demographics
NPI:1477862522
Name:MARCUS DALY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:MARCUS DALY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:RAVALLI UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DONJA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ERDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-363-2211
Mailing Address - Street 1:1224 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2338
Mailing Address - Country:US
Mailing Address - Phone:406-375-4823
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1224 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2338
Practice Address - Country:US
Practice Address - Phone:406-375-4888
Practice Address - Fax:406-375-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT208800000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477862522Medicaid
MT1477862522Medicaid
ID1477862522Medicaid