Provider Demographics
NPI:1790870442
Name:BIG SKY MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:BIG SKY MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-443-7733
Mailing Address - Street 1:820 N MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3856
Mailing Address - Country:US
Mailing Address - Phone:406-443-7733
Mailing Address - Fax:406-443-8292
Practice Address - Street 1:820 N MONTANA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3856
Practice Address - Country:US
Practice Address - Phone:406-443-7733
Practice Address - Fax:406-443-8292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9893207Q00000X
MT9754207Q00000X, 2081P2900X
MT469363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000084366Medicare ID - Type UnspecifiedBIG SKY MEDICAL CLINIC