Provider Demographics
NPI:1821063868
Name:COLSTRIP MEDICAL CENTER
Entity Type:Organization
Organization Name:COLSTRIP MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-748-3600
Mailing Address - Street 1:6230 MAIN
Mailing Address - Street 2:
Mailing Address - City:COLSTRIP
Mailing Address - State:MT
Mailing Address - Zip Code:59323-1858
Mailing Address - Country:US
Mailing Address - Phone:406-748-3600
Mailing Address - Fax:406-748-3606
Practice Address - Street 1:6230 MAIN
Practice Address - Street 2:
Practice Address - City:COLSTRIP
Practice Address - State:MT
Practice Address - Zip Code:59323-1858
Practice Address - Country:US
Practice Address - Phone:406-748-3600
Practice Address - Fax:406-748-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT207Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0005603047Medicaid
MT0421107Medicaid
MT000005681OtherBLUE SHIELD PROVIDER NUMB