Provider Demographics
NPI:1841414026
Name:POWELL COUNTY MEMORIAL HOSPITAL ASSN INC DBA DEER LODGE MEDICAL CENTER
Entity Type:Organization
Organization Name:POWELL COUNTY MEMORIAL HOSPITAL ASSN INC DBA DEER LODGE MEDICAL CENTER
Other - Org Name:DEER LODGE MEDICAL CENTER-CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAENA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-846-7717
Mailing Address - Street 1:1100 HOLLENBACK LANE
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722-1828
Mailing Address - Country:US
Mailing Address - Phone:406-846-1722
Mailing Address - Fax:406-846-3074
Practice Address - Street 1:1100 HOLLENBACK LANE
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-1828
Practice Address - Country:US
Practice Address - Phone:406-846-1722
Practice Address - Fax:406-846-2789
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POWELL COUNTY MEMORIAL HOSPITAL ASSOCIATION INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-12
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0720171Medicaid
MT273991Medicare ID - Type Unspecified
MT0720171Medicaid