Basic Information
| Provider Information | |||||||||
| NPI: | 1528167905 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SHERIDAN COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 445 CENTENNIAL AVE | ||||||||
| Address2: | SHERIDAN COMMUNITY HEALTH CENTER | ||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067234075 | ||||||||
| FaxNumber: | 4064966035 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 MADISON | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597490245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068425103 | ||||||||
| FaxNumber: | 4068425110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STERGAR | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4067234075 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BUTTE SILVER PRIMARY HEALTH CARE CLINIC, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 95608222 | 01 | MO | MT BREAST & CERVICAL PROG | OTHER | 0730028 | 05 | MT | MEDICAID | 63392 | 01 | MT | BCBS | OTHER | CK5130 | 01 | MT | RAILROAD MEDICARE | OTHER |