Provider Demographics
NPI:1609983352
Name:ERCANBRACK, LANCE L (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:L
Last Name:ERCANBRACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 LOUISIANA AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2158
Mailing Address - Country:US
Mailing Address - Phone:406-283-6800
Mailing Address - Fax:406-283-6815
Practice Address - Street 1:308 LOUISIANA AVE
Practice Address - Street 2:STE 1
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2158
Practice Address - Country:US
Practice Address - Phone:406-283-6800
Practice Address - Fax:406-283-6815
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0022899Medicaid
MT01553OtherBC/BS
MT000081524Medicare PIN
MT01553OtherBC/BS