Provider Demographics
NPI:1669652087
Name:RIVER GATES NEPHROLOGY, PC
Entity Type:Organization
Organization Name:RIVER GATES NEPHROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PINCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-457-4280
Mailing Address - Street 1:2525 E BROADWAY ST STE 202A
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-8049
Mailing Address - Country:US
Mailing Address - Phone:406-457-4280
Mailing Address - Fax:406-457-4278
Practice Address - Street 1:2525 E BROADWAY ST STE 202A
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8049
Practice Address - Country:US
Practice Address - Phone:406-457-4280
Practice Address - Fax:406-457-4278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000083896OtherMEDICARE INDIVIDUAL
MT0073355Medicaid
MTH68542Medicare UPIN