Provider Demographics
NPI:1639126303
Name:MISSOULA BONE & JOINT SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MISSOULA BONE & JOINT SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:406-721-4436
Mailing Address - Street 1:2360 MULLAN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-542-9695
Mailing Address - Fax:406-542-9703
Practice Address - Street 1:2360 MULLAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-542-9695
Practice Address - Fax:406-542-9703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000351084Medicaid
MT0000351084Medicaid