Provider Demographics
NPI:1447207212
Name:MISSOULA BONE & JOINT, LLC
Entity Type:Organization
Organization Name:MISSOULA BONE & JOINT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:406-721-4436
Mailing Address - Street 1:2360 MULLAN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-721-4436
Mailing Address - Fax:406-721-6053
Practice Address - Street 1:2360 MULLAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-721-4436
Practice Address - Fax:406-721-6053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000081217Medicare PIN
MT1283650001Medicare NSC