Provider Demographics
NPI:1356317010
Name:CARLSON, MARYANN (MD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 31585
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-1585
Mailing Address - Country:US
Mailing Address - Phone:406-752-3239
Mailing Address - Fax:406-752-3252
Practice Address - Street 1:PO BOX 1459
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-1459
Practice Address - Country:US
Practice Address - Phone:406-892-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4176208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0102782Medicaid
MT0000095390OtherBCBS OB PHYS GRP
MT0102782Medicaid