Basic Information
| Provider Information | |||||||||
| NPI: | 1649401076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES MT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PMG MT IHI MONTANA CARDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065417000 | ||||||||
| FaxNumber: | 4065417001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2829 GREAT NORTHERN LOOP | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065417000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2009 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR REIMB REG STRAT/ASST SEC ENROLL | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HEALTH & SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.