Provider Demographics
NPI:1336499680
Name:WHITEFISH DERMATOLOGY LLC
Entity Type:Organization
Organization Name:WHITEFISH DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:PYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-791-2708
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-0640
Mailing Address - Country:US
Mailing Address - Phone:406-862-7546
Mailing Address - Fax:
Practice Address - Street 1:401 BAKER AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2499
Practice Address - Country:US
Practice Address - Phone:406-862-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12763207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALAP2520915OtherDEA
ALC71888Medicare UPIN