Provider Demographics
NPI:1477020824
Name:BOZEMAN PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:BOZEMAN PRIMARY CARE PLLC
Other - Org Name:BOZEMAN PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-404-1525
Mailing Address - Street 1:4535 VALLEY COMMONS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-4160
Mailing Address - Country:US
Mailing Address - Phone:406-404-1525
Mailing Address - Fax:406-548-9777
Practice Address - Street 1:4535 VALLEY COMMONS DR STE 104
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4160
Practice Address - Country:US
Practice Address - Phone:406-404-1525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT8210759Medicaid