Basic Information
| Provider Information | |||||||||
| NPI: | 1114947843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JASUMBACK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 26TH ST S | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064555200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 26TH ST S | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064555200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A64035 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A640350 | 05 | CA | MEDICAID | 00A640350 | 01 | CA | BLUE SHIELD | OTHER | 1114947843 | 05 | MT | MEDICAID |