Provider Demographics
NPI:1609932037
Name:CLOSE, MICHAEL JON (RPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JON
Last Name:CLOSE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911-1527
Mailing Address - Country:US
Mailing Address - Phone:406-837-6892
Mailing Address - Fax:406-837-6435
Practice Address - Street 1:850 HOLT DRIVE
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911
Practice Address - Country:US
Practice Address - Phone:406-837-6892
Practice Address - Fax:406-837-6435
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1350PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT61996OtherBCBS OF MONTANA PROVIDER
MT0000345185Medicaid