Provider Demographics
NPI:1083626832
Name:ALPINE ORTHOPEDICS & SPORTS MEDICINE
Entity Type:Organization
Organization Name:ALPINE ORTHOPEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-586-8029
Mailing Address - Street 1:536 COTTONWOOD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718
Mailing Address - Country:US
Mailing Address - Phone:406-586-8029
Mailing Address - Fax:406-586-8009
Practice Address - Street 1:536 COTTONWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:406-586-8029
Practice Address - Fax:406-586-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QS0010X, 207XX0005X, 207XX0801X, 363AM0700X, 363AS0400X
MT8221207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1194070001Medicare NSC
MT000083502Medicare PIN
MT000083502Medicare UPIN