Provider Demographics
NPI:1841320629
Name:SURGICAL ASSOCIATES OF BOZEMAN, PC
Entity type:Organization
Organization Name:SURGICAL ASSOCIATES OF BOZEMAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-587-0704
Mailing Address - Street 1:925 HIGHLAND BOULEVARD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6900
Mailing Address - Country:US
Mailing Address - Phone:406-587-0704
Mailing Address - Fax:406-587-1147
Practice Address - Street 1:925 HIGHLAND BOULEVARD
Practice Address - Street 2:SUITE 1200
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6900
Practice Address - Country:US
Practice Address - Phone:406-587-0704
Practice Address - Fax:406-587-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT15264163WM0705X
MT4000208600000X
MT6438208600000X
MT9898208600000X
MT10338208600000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000062917Medicaid
MT000048568Medicaid
MT000037700Medicaid
MT000085748Medicaid
MTH84227Medicare UPIN
MT000083303Medicare ID - Type UnspecifiedANDREW W. GRACE, MD
MT000062917Medicaid
MTH40343Medicare UPIN
MT000009823Medicare ID - Type UnspecifiedKELLY L. BANKS, MD
MT000037700Medicaid
MT000085748Medicaid
MTE28053Medicare UPIN
MT000082045Medicare ID - Type UnspecifiedGARTH A. OLDS, MD