Provider Demographics
NPI:1619925575
Name:MCGREGOR, JON BRANT (M D)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:BRANT
Last Name:MCGREGOR
Suffix:
Gender:M
Credentials:M D
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 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:
Practice Address - Street 1:500 W BROADWAY ST STE 320
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:406-329-5606
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7580207RC0000X, 207UN0901X
MTMED-PHYS-LIC-89184207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132066508Medicaid
TXP00411171OtherRAILROAD MEDICARE
TXF99603Medicare UPIN
TXP00411171OtherRAILROAD MEDICARE