Basic Information
| Provider Information | |||||||||
| NPI: | 1124065776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAIDLE | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | ROBIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAIDLE | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1456 | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599171456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062973915 | ||||||||
| FaxNumber: | 4062973364 | ||||||||
| Practice Location | |||||||||
| Address1: | 1343 US HIGHWAY 93 N | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599179503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062973915 | ||||||||
| FaxNumber: | 4062973364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 783PT | MT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1124065776 | 05 | MT | MEDICAID | 1124065776 | 01 | MT | BCBS | OTHER |