Provider Demographics
NPI:1821182627
Name:LANDSVERK, BRIAN KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KENNETH
Last Name:LANDSVERK
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 1:1125 EAST BABCOCK
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-580-7642
Mailing Address - Fax:
Practice Address - Street 1:915 HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6902
Practice Address - Country:US
Practice Address - Phone:406-586-3309
Practice Address - Fax:406-522-8498
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8647207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000097121OtherBLUE CROSS BLUE SHIELD
MT0039695Medicaid
810480698OtherEIN IRS
MT000097121OtherBLUE CROSS BLUE SHIELD
810480698OtherEIN IRS