Basic Information
| Provider Information | |||||||||
| NPI: | 1720222508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSTER | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | MUIR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2360 MULLAN RD, STE C | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4067216053 | ||||||||
| Practice Location | |||||||||
| Address1: | 2360 MULLAN RD STE C | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4067216053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207XX0004X | MD158161 | OR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0004X | A130888 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0004X | 15371 | NV | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207XX0004X | MED-PHYS-LIC-36762 | MT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1720222508 | 05 | NV | MEDICAID |