Provider Demographics
NPI:1720222508
Name:ROSTER, BRENT MUIR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MUIR
Last Name:ROSTER
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 1:2360 MULLAN RD, STE C
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-721-4436
Mailing Address - Fax:406-721-6053
Practice Address - Street 1:2360 MULLAN RD STE C
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-721-4436
Practice Address - Fax:406-721-6053
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD158161207XX0004X
CAA130888207XX0004X
NV15371207XX0004X
390200000X
MTMED-PHYS-LIC-36762207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1720222508Medicaid
NV1720222508Medicaid