Provider Demographics
NPI:1679583892
Name:PAUL, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PAUL
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:PO BOX 16900
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-6900
Mailing Address - Country:US
Mailing Address - Phone:406-327-4620
Mailing Address - Fax:406-549-5928
Practice Address - Street 1:3800 EASTSIDE HWY
Practice Address - Street 2:STEVENSVILLE COMMUNITY MEDICAL CENTER
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870
Practice Address - Country:US
Practice Address - Phone:406-777-2775
Practice Address - Fax:406-777-2796
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT5294207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000095960OtherBCBS
MT0076700Medicaid
MT000095960OtherBCBS
000009596Medicare ID - Type Unspecified