Provider Demographics
NPI:1790705564
Name:GLACIER EYE CLINIC PC
Entity Type:Organization
Organization Name:GLACIER EYE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-752-8825
Mailing Address - Street 1:175 TIMBERWOLF PKWY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1218
Mailing Address - Country:US
Mailing Address - Phone:406-257-2020
Mailing Address - Fax:406-257-5554
Practice Address - Street 1:175 TIMBERWOLF PKWY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1218
Practice Address - Country:US
Practice Address - Phone:406-257-2020
Practice Address - Fax:406-257-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0409710001Medicare NSC