Provider Demographics
NPI:1972811420
Name:PREMIER CARE PEDIATRICS & FAMILY PRACTICE
Entity Type:Organization
Organization Name:PREMIER CARE PEDIATRICS & FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-455-5437
Mailing Address - Street 1:1300 28TH ST S
Mailing Address - Street 2:SUITE 6
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5296
Mailing Address - Country:US
Mailing Address - Phone:406-455-5437
Mailing Address - Fax:406-455-4365
Practice Address - Street 1:1300 28TH ST S
Practice Address - Street 2:SUITE 6
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5296
Practice Address - Country:US
Practice Address - Phone:406-455-5437
Practice Address - Fax:406-455-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8726261QP2300X
MTAPN13634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0117062Medicaid