Healthcare Provider Details

I. General information

NPI: 1104882232
Provider Name (Legal Business Name): GLACIER MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 BAKER AVE
WHITEFISH MT
59937-2901
US

IV. Provider business mailing address

1111 BAKER AVE
WHITEFISH MT
59937-2901
US

V. Phone/Fax

Practice location:
  • Phone: 406-862-2515
  • Fax: 406-862-4229
Mailing address:
  • Phone: 406-862-2515
  • Fax: 406-862-4229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLI D MEUCHEL
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 406-862-2515