Provider Demographics
NPI:1447251327
Name:GREAT FALLS CLINIC SURGERY CENTER LLC
Entity type:Organization
Organization Name:GREAT FALLS CLINIC SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CORNWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-216-8057
Mailing Address - Street 1:1509 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5363
Mailing Address - Country:US
Mailing Address - Phone:406-771-3500
Mailing Address - Fax:406-771-3502
Practice Address - Street 1:1509 29TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5363
Practice Address - Country:US
Practice Address - Phone:406-771-3500
Practice Address - Fax:406-771-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9722261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0350829Medicaid
27C0001016OtherCMS (FORMERLY HCFA)
MTM000005703Medicare Oscar/Certification
MT0350829Medicaid