Provider Demographics
NPI:1013035666
Name:DR J GENERAL SURGERY PLLC
Entity Type:Organization
Organization Name:DR J GENERAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:JANCZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-541-2570
Mailing Address - Street 1:2835 FORT MISSOULA ROAD STE 306
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804
Mailing Address - Country:US
Mailing Address - Phone:406-541-2570
Mailing Address - Fax:406-541-2573
Practice Address - Street 1:2835 FORT MISSOULA RD STE 306
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7424
Practice Address - Country:US
Practice Address - Phone:406-541-2570
Practice Address - Fax:406-541-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8688208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0062169Medicaid
MT0062169Medicaid