Provider Demographics
NPI:1104882232
Name:GLACIER MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:GLACIER MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEUCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-862-2515
Mailing Address - Street 1:1111 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2901
Mailing Address - Country:US
Mailing Address - Phone:406-862-2515
Mailing Address - Fax:406-862-4229
Practice Address - Street 1:1111 BAKER AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2901
Practice Address - Country:US
Practice Address - Phone:406-862-2515
Practice Address - Fax:406-862-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1104882232OtherGLACIER MEDICAL ASSOC NPI
MT27D0411341OtherCLIA ID#--LAB CERT
MT99882551Medicaid
WA0026899OtherWASH. DEP LABOR GRP ID#
WA0026899OtherWASH. DEP LABOR GRP ID#
MT1104882232OtherGLACIER MEDICAL ASSOC NPI
WA0026899OtherWASH. DEP LABOR GRP ID#
MT27D0411341OtherCLIA ID#--LAB CERT