Provider Demographics
NPI:1306055645
Name:FETAL DIAGNOSTIC CENTER PC
Entity type:Organization
Organization Name:FETAL DIAGNOSTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-238-5888
Mailing Address - Street 1:2900 12TH AVE N STE 130W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7595
Mailing Address - Country:US
Mailing Address - Phone:406-237-5888
Mailing Address - Fax:406-237-5899
Practice Address - Street 1:2900 12TH AVE N STE 130W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7595
Practice Address - Country:US
Practice Address - Phone:406-237-5888
Practice Address - Fax:406-237-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8687207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000017663Medicaid
MTE07522Medicare UPIN