Basic Information
| Provider Information | |||||||||
| NPI: | 1669791786 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES MT | ||||||||
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| OtherOrganizationName: | PMG WMT FLORENCE FAMILY MED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062734923 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5549 OLD HWY 93 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598336545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062734923 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2010 | ||||||||
| LastUpdateDate: | 04/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST SEC ENROLLMENT/DIR REIMB ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.