=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760836167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YELLOWSTONE SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2016
-----------------------------------------------------
Last Update Date | 04/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1739 SPRING CREEK DR
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-6747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-237-5900
-----------------------------------------------------
Fax | 406-237-5910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31715
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59107-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-237-5900
-----------------------------------------------------
Fax | 406-237-5910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ROBERT GAGNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-237-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------