Basic Information
| Provider Information | |||||||||
| NPI: | 1366640484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMRINE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | YOST-ARCH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2360 MULLAN RD | ||||||||
| Address2: | STE C | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083676042 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2360 MULLAN RD STE C | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4067216053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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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 | 207Q00000X | MR-0925 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-10516 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 12629 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 807771700 | 05 | ID | MEDICAID | 1196275 | 01 | ID | MEDICARE PTAN | OTHER |