Provider Demographics
NPI:1336380161
Name:PROVIDENCE HEALTH & SERVICES MT
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:PMG MT INFECTION DISEASE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST SEC OF ENROLLMENT/DIR REIMB
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:425-687-3615
Practice Address - Street 1:902 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2928
Practice Address - Country:US
Practice Address - Phone:406-321-1732
Practice Address - Fax:425-687-3615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-06
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN