Provider Demographics
NPI:1366200206
Name:THE MATRIARCH CLINIC
Entity type:Organization
Organization Name:THE MATRIARCH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MICHELE ENTERLINE
Authorized Official - Last Name:CONSSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-606-0332
Mailing Address - Street 1:2975 MAX AVE # 1187
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-7143
Mailing Address - Country:US
Mailing Address - Phone:406-414-0020
Mailing Address - Fax:888-289-4505
Practice Address - Street 1:62 TILLYFOUR RD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-9666
Practice Address - Country:US
Practice Address - Phone:406-414-0020
Practice Address - Fax:888-289-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty