Provider Demographics
NPI:1649401076
Name:PROVIDENCE HEALTH & SERVICES MT
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:PMG MT IHI MONTANA CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REIMB REG STRAT/ASST SEC ENROLL
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:406-541-7000
Mailing Address - Fax:406-541-7001
Practice Address - Street 1:2829 GREAT NORTHERN LOOP
Practice Address - Street 2:SUITE 300
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1752
Practice Address - Country:US
Practice Address - Phone:406-541-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-03
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN