MEDICARE: BIG SKY SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	10470	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	02-02051-9	OTHER	MT	MT STATE FUND
3	06036-2	OTHER	MT	BLUE CROSS BLUE SHIELD
4	184874300	OTHER	MT	OWCP

General Provider Information

NPI Number	:	1639158645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG SKY SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	2833 FORT MISSOULA RD
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-7408
Country	:	US
Telephone Number	:	406-542-6559
Fax Number	:	406-542-9040

Provider Business Practice Location Address
First Line	:	2833 FORT MISSOULA RD
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-7408
Country	:	US
Telephone Number	:	406-542-6559
Fax Number	:	406-542-9040

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIEL BRABY
Credential	:	MD
Telephone Number	:	406-541-3277

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	11/19/2009

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