Provider Demographics
NPI:1508845363
Name:BOZEMAN MANUAL THERAPY PC
Entity Type:Organization
Organization Name:BOZEMAN MANUAL THERAPY PC
Other - Org Name:STEPHEN L HISEY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HISEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-587-6057
Mailing Address - Street 1:1700 WEST KOCH
Mailing Address - Street 2:SUITE 12
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-587-6057
Mailing Address - Fax:406-587-2177
Practice Address - Street 1:1700 WEST KOCH
Practice Address - Street 2:SUITE 12
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-587-6057
Practice Address - Fax:406-587-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT633PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT61058OtherBLUE CROSS BLUE SHIELD
MT3401139Medicaid
MT=========OtherMT STATE FUND WORK COMP