Provider Demographics
NPI:1053321273
Name:DANICICH, MICHELE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:DANICICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-329-5781
Mailing Address - Fax:
Practice Address - Street 1:900 N ORANGE ST STE 304
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2951
Practice Address - Country:US
Practice Address - Phone:406-329-5781
Practice Address - Fax:406-327-3331
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT8723207RE0101X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011000773Medicare PIN
G50831Medicare UPIN
MTM011005275Medicare PIN
G50831Medicare UPIN
MTM011005275Medicare PIN