Provider Demographics
NPI:1477661874
Name:ALLERGY AND INFUSION SERVICES OF MISSOULA, PLLC
Entity type:Organization
Organization Name:ALLERGY AND INFUSION SERVICES OF MISSOULA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:WARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-728-5428
Mailing Address - Street 1:2825 FORT MISSOULA RD
Mailing Address - Street 2:SUITE 317C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7420
Mailing Address - Country:US
Mailing Address - Phone:406-728-5428
Mailing Address - Fax:406-728-5458
Practice Address - Street 1:2825 FORT MISSOULA RD
Practice Address - Street 2:SUITE 317C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7420
Practice Address - Country:US
Practice Address - Phone:406-728-5428
Practice Address - Fax:406-728-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7276207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTA39086Medicare UPIN