Provider Demographics
NPI:1013004241
Name:MONTANA SPORT AND SPINE LLC
Entity Type:Organization
Organization Name:MONTANA SPORT AND SPINE LLC
Other - Org Name:BOZEMAN SPORT AND SPINE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:AYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-522-9067
Mailing Address - Street 1:925 HIGHLAND BLVD, SUITE 1130
Mailing Address - Street 2:MONTANA SPORT AND SPINE LLC
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6900
Mailing Address - Country:US
Mailing Address - Phone:406-522-9067
Mailing Address - Fax:406-522-9074
Practice Address - Street 1:925 HIGHLAND BLVD, SUITE 1130
Practice Address - Street 2:BOZEMAN SPORT AND SPINE LLC
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6900
Practice Address - Country:US
Practice Address - Phone:406-522-9067
Practice Address - Fax:406-522-9074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT103812081P2900X
2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000099205OtherBLUE CROSS BLUE SHIELD
MTDC7699OtherRAILROAD MEDICARE
MTDC7699OtherRAILROAD MEDICARE