Provider Demographics
NPI:1588834279
Name:MEDICINE TREE PRIMARY CARE INC
Entity Type:Organization
Organization Name:MEDICINE TREE PRIMARY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDIENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:406-295-5752
Mailing Address - Street 1:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MT
Mailing Address - Zip Code:59935-3007
Mailing Address - Country:US
Mailing Address - Phone:406-295-5752
Mailing Address - Fax:406-295-0314
Practice Address - Street 1:318 E KOOTENAI AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MT
Practice Address - Zip Code:59935
Practice Address - Country:US
Practice Address - Phone:406-295-5752
Practice Address - Fax:406-295-0314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTD107540261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT500024254OtherRAILROAD MEDICARE