Provider Demographics
NPI:1760688238
Name:EASTERN PLAINS-CLINIC OF UROLOGY, LLC
Entity type:Organization
Organization Name:EASTERN PLAINS-CLINIC OF UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ERVIN
Authorized Official - Last Name:KUGLITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-623-9970
Mailing Address - Street 1:630 W MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1510
Mailing Address - Country:US
Mailing Address - Phone:920-623-9970
Mailing Address - Fax:920-623-9989
Practice Address - Street 1:630 W MERCURY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1510
Practice Address - Country:US
Practice Address - Phone:920-623-9970
Practice Address - Fax:920-623-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7089208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0020103002Medicaid
WI30673100Medicaid
MT0081226Medicaid
MTB54363Medicare UPIN
MT0081226Medicaid