Basic Information
| Provider Information | |||||||||
| NPI: | 1730325440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES MT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PMG MT MONTANA INTERNAL MED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063271918 | ||||||||
| FaxNumber: | 4063292937 | ||||||||
| Practice Location | |||||||||
| Address1: | 2819 GREAT NORTHERN LOOP | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065431197 | ||||||||
| FaxNumber: | 4065430515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 11/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | BODLOVIC | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4063271918 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HEALTH & SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0411866 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.