Provider Demographics
NPI:1497058572
Name:MONTANA FOOT AND ANKLE INSTITUTE, PLLC
Entity Type:Organization
Organization Name:MONTANA FOOT AND ANKLE INSTITUTE, PLLC
Other - Org Name:MISSOULA FOOT AND ANKLE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MANGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:406-552-5050
Mailing Address - Street 1:2825 FORT MISSOULA RD
Mailing Address - Street 2:SUITE #106
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7420
Mailing Address - Country:US
Mailing Address - Phone:406-543-5333
Mailing Address - Fax:406-543-5621
Practice Address - Street 1:2825 FORT MISSOULA RD
Practice Address - Street 2:SUITE #106
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7420
Practice Address - Country:US
Practice Address - Phone:406-543-5333
Practice Address - Fax:406-543-5621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT174261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011000091OtherMEDICARE PTAN
MTM011000091OtherMEDICARE PTAN