Provider Demographics
NPI:1861523649
Name:ALPINE FAMILY MEDICINE PC
Entity type:Organization
Organization Name:ALPINE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:GEDLAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-892-1011
Mailing Address - Street 1:734 9TH ST W
Mailing Address - Street 2:SUITE 12
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-3859
Mailing Address - Country:US
Mailing Address - Phone:406-892-1011
Mailing Address - Fax:406-892-2108
Practice Address - Street 1:734 9TH ST W
Practice Address - Street 2:SUITE 12
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-3859
Practice Address - Country:US
Practice Address - Phone:406-892-1011
Practice Address - Fax:406-892-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT312363AM0700X
MT10336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0083874Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER