Provider Demographics
NPI:1356367940
Name:PANCICH, KEVIN R (DPT ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:PANCICH
Suffix:
Gender:M
Credentials:DPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 ELLIS STREET
Mailing Address - Street 2:STE 201
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-587-4501
Mailing Address - Fax:406-587-3919
Practice Address - Street 1:1532 ELLIS STREET
Practice Address - Street 2:STE 201
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-587-4501
Practice Address - Fax:406-587-3919
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1939PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3401788Medicaid
MTP00328588OtherRAILROAD MEDICARE