Basic Information
| Provider Information | |||||||||
| NPI: | 1588848956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANITE PHYSICAL THERAPY & SPORTS | ||||||||
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| OtherOrganizationName: | ORTHO MONTANA PHYSICAL THERAPY WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3838 AVENUE B STE B | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591027550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062386535 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 12TH AVE N STE 140W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062375050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCDOWELL | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4062375050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.