Provider Demographics
NPI:1760493225
Name:MISSOULA FAMILY MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:MISSOULA FAMILY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PRIDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-728-3111
Mailing Address - Street 1:621 W ALDER ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4014
Mailing Address - Country:US
Mailing Address - Phone:406-728-3111
Mailing Address - Fax:406-728-3116
Practice Address - Street 1:621 W ALDER ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4014
Practice Address - Country:US
Practice Address - Phone:406-728-3111
Practice Address - Fax:406-728-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT6053320001Medicare NSC