Basic Information
| Provider Information | |||||||||
| NPI: | 1528281110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN MONTANA HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHERN MONTANA LIFELINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1231 | ||||||||
| Address2: | |||||||||
| City: | HAVRE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 595011231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062652211 | ||||||||
| FaxNumber: | 4052651651 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 13TH ST | ||||||||
| Address2: | |||||||||
| City: | HAVRE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 595015222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062652211 | ||||||||
| FaxNumber: | 4062651651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 4062652211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHERN MONTANA HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 10830 | MT | N | Agencies | Home Health | 332BC3200X | 10830 | MT | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 0632125 | 05 | MT | MEDICAID |