Provider Demographics
NPI:1346326824
Name:RAVALLI FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:RAVALLI FAMILY MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARDER-BRONWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-363-5104
Mailing Address - Street 1:411 W. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2470
Mailing Address - Country:US
Mailing Address - Phone:406-363-5104
Mailing Address - Fax:406-363-2894
Practice Address - Street 1:411 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2470
Practice Address - Country:US
Practice Address - Phone:406-363-5104
Practice Address - Fax:406-363-2894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT273829Medicare Oscar/Certification
MT000083729Medicare PIN