Provider Demographics
NPI:1639475411
Name:STATE OF MONTANA
Entity Type:Organization
Organization Name:STATE OF MONTANA
Other - Org Name:CHILDREN'S SPECIAL HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:S
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-444-3529
Mailing Address - Street 1:PO BOX 202951
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59620-2951
Mailing Address - Country:US
Mailing Address - Phone:406-444-3529
Mailing Address - Fax:406-444-2750
Practice Address - Street 1:1400 BROADWAY RM A116
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59620
Practice Address - Country:US
Practice Address - Phone:406-444-3529
Practice Address - Fax:406-444-2750
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MONTANA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT92046OtherBLUE CROSS BLUE SHELD OF MONTANA
MT0260000Medicaid
MT92056OtherBLUE CROSS BLUE SHELD OF MONTANA
MT99248OtherBLUE CROSS BLUE SHELD OF MONTANA