Provider Demographics
NPI:1619054681
Name:MERCURY STREET MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:MERCURY STREET MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:G
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-723-1300
Mailing Address - Street 1:300 W MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1652
Mailing Address - Country:US
Mailing Address - Phone:406-723-1300
Mailing Address - Fax:406-723-1335
Practice Address - Street 1:300 W MERCURY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1652
Practice Address - Country:US
Practice Address - Phone:406-723-1300
Practice Address - Fax:406-723-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1074257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty