Provider Demographics
NPI:1811966526
Name:DANIELL, SUZANNE
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:DANIELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 BAKER AVE
Mailing Address - Street 2:GLACIER MEDICAL ASSOCIATES
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2901
Mailing Address - Country:US
Mailing Address - Phone:406-862-2515
Mailing Address - Fax:406-862-4229
Practice Address - Street 1:1111 BAKER AVE
Practice Address - Street 2:GLACIER MEDICAL ASSOCIATES
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2901
Practice Address - Country:US
Practice Address - Phone:406-862-2515
Practice Address - Fax:406-862-4229
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT7550207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1104882232OtherGLACIER MEDICAL ASSOC NPI
NH27D0411341OtherCLIA ID#--LAB CERT
MT810350909OtherFEIN
MT0108836Medicaid
MT7550OtherMONTANA STATE LICENSE
MT000008287OtherMEDICARE PART B GRP ID#
MT110174719OtherRAILROAD MEDICARE PIN#
MTCI2709OtherRAILROAD MEDICARE GRP #
MT000007591OtherBLUE CROSS/SHIELD PIN
MTCI2709OtherRAILROAD MEDICARE GRP #
MTE98286Medicare UPIN
MT000008287OtherMEDICARE PART B GRP ID#
MT7550OtherMONTANA STATE LICENSE