Provider Demographics
NPI:1679865497
Name:PROVIDENCE HEALTH & SERVICES MT
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:PMG MT IHI SEELEY SWAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCM OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-329-5795
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-1918
Mailing Address - Fax:
Practice Address - Street 1:3050 HIGHWAY 83 N
Practice Address - Street 2:
Practice Address - City:SEELEY LAKE
Practice Address - State:MT
Practice Address - Zip Code:59868
Practice Address - Country:US
Practice Address - Phone:866-366-2983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN