Provider Demographics
NPI:1215108576
Name:PARK CLINIC OB-GYN
Entity type:Organization
Organization Name:PARK CLINIC OB-GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-823-6611
Mailing Address - Street 1:320 ALPENGLOW LN
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-8506
Mailing Address - Country:US
Mailing Address - Phone:406-222-0800
Mailing Address - Fax:406-222-7606
Practice Address - Street 1:300 N WILLSON AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3551
Practice Address - Country:US
Practice Address - Phone:406-222-0605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVINGSTON HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTCI1266Medicare PIN