Provider Demographics
NPI:1548394836
Name:PROVIDENCE ST JOSEPH MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE ST JOSEPH MEDICAL CENTER
Other - Org Name:PROV ST JOSEPH MED CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO WESTERN MONTANA REGION
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-329-5868
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-1010
Mailing Address - Country:US
Mailing Address - Phone:406-883-5377
Mailing Address - Fax:
Practice Address - Street 1:6 13TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5315
Practice Address - Country:US
Practice Address - Phone:406-883-5377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-16
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009912Medicare PIN
MT000085149Medicare PIN