Provider Demographics
NPI:1811918998
Name:TOBACCO ROOT ANESTHESIOLOGY, LLC
Entity type:Organization
Organization Name:TOBACCO ROOT ANESTHESIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:VANDOLAH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA,MAE
Authorized Official - Phone:406-285-6588
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-1330
Mailing Address - Country:US
Mailing Address - Phone:406-285-6588
Mailing Address - Fax:406-285-9012
Practice Address - Street 1:7 VANDOLAH RD
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-8673
Practice Address - Country:US
Practice Address - Phone:406-285-6588
Practice Address - Fax:406-285-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN14372367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4308525Medicaid
MT4308525Medicaid