Basic Information
| Provider Information | |||||||||
| NPI: | 1790950889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TYSVER | ||||||||
| OtherFirstName: | THOMAS | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2900 12TH AVE N STE 140W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062375050 | ||||||||
| FaxNumber: | 4062386599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 12TH AVE N STE 140W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591017507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062375050 | ||||||||
| FaxNumber: | 4062386599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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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 | 207X00000X | 266008 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 26885 | MT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 233648 | 05 | MA | MEDICAID |