Basic Information
| Provider Information | |||||||||
| NPI: | 1073523635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENDIVE MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 202 PROSPECT DR | ||||||||
| Address2: | |||||||||
| City: | GLENDIVE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593301943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063453306 | ||||||||
| FaxNumber: | 4063453358 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 PROSPECT DR | ||||||||
| Address2: | |||||||||
| City: | GLENDIVE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593301943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063453306 | ||||||||
| FaxNumber: | 4063453358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4063458924 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 10541 | MT | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 00003100110 | 05 | MT | MEDICAID | 00082 | 01 | MT | BLUE CROSS | OTHER |