Provider Demographics
NPI:1508944505
Name:PONDERA MEDICAL CENTER DUTTON CLINIC
Entity Type:Organization
Organization Name:PONDERA MEDICAL CENTER DUTTON CLINIC
Other - Org Name:PONDERA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-271-3211
Mailing Address - Street 1:805 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-0758
Mailing Address - Country:US
Mailing Address - Phone:406-271-2202
Mailing Address - Fax:406-271-3917
Practice Address - Street 1:17 MAIN ST WEST
Practice Address - Street 2:
Practice Address - City:DUTTON
Practice Address - State:MT
Practice Address - Zip Code:59433
Practice Address - Country:US
Practice Address - Phone:406-271-2202
Practice Address - Fax:406-271-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT00066442OtherBCBS
MT0036582Medicaid
MT0036582Medicaid
MT000009935Medicare PIN