Provider Demographics
NPI:1871716936
Name:BIGFORK MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:BIGFORK MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:JENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-837-5541
Mailing Address - Street 1:8299 MT HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911-3583
Mailing Address - Country:US
Mailing Address - Phone:406-837-5541
Mailing Address - Fax:406-837-5543
Practice Address - Street 1:8299 MT HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911-3583
Practice Address - Country:US
Practice Address - Phone:406-837-5541
Practice Address - Fax:406-837-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0149345Medicaid
MT16140OtherBLUESHIELD OF MONTANA
MT92136OtherBLUESHIELD OF MONTANA
MT0067171Medicaid
MTD20611Medicare UPIN
MT0149345Medicaid