Provider Demographics
NPI:1831105394
Name:SWANSON, NEIL AXEL (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:AXEL
Last Name:SWANSON
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2875 TINA AVE STE 104
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1582
Practice Address - Country:US
Practice Address - Phone:406-613-7676
Practice Address - Fax:406-206-6316
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16342207N00000X
MT18609207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000617Medicaid
OR000617Medicaid