Basic Information
| Provider Information | |||||||||
| NPI: | 1093726796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN EYE SURGERY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W KENT AVE | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598016772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413806 | ||||||||
| FaxNumber: | 4065413811 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 WEST KENT | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413883 | ||||||||
| FaxNumber: | 4065413884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4065413937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 11789 | MT | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3507569 | 05 | MT | MEDICAID | 60112 | 01 | MT | BC | OTHER |