Basic Information
| Provider Information | |||||||||
| NPI: | 1144260514 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INFECTIOUS DISEASE SPECIALISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8897 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598078897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067216221 | ||||||||
| FaxNumber: | 4067216221 | ||||||||
| Practice Location | |||||||||
| Address1: | 614 W SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063271666 | ||||||||
| FaxNumber: | 4063295606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | WILLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4067216221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 6638 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 0154581 | 05 | MT | MEDICAID | P00185637 | 01 | RR MEDICARE | OTHER | 1073553491 | 05 | MT | MEDICAID | 92275 | 01 | BCBS | OTHER |