Provider Demographics
NPI:1609064013
Name:MISSOULA UROLOGY PLLC
Entity Type:Organization
Organization Name:MISSOULA UROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRABER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-543-1967
Mailing Address - Street 1:2835 FORT MISSOULA RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7423
Mailing Address - Country:US
Mailing Address - Phone:406-543-1967
Mailing Address - Fax:406-543-5379
Practice Address - Street 1:2835 FORT MISSOULA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7423
Practice Address - Country:US
Practice Address - Phone:406-543-1967
Practice Address - Fax:406-543-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTG475762088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty