Provider Demographics
NPI:1649277567
Name:STIMAC, BLAINE (PT,MS)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:STIMAC
Suffix:
Gender:M
Credentials:PT,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 COMMONS WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1906
Mailing Address - Country:US
Mailing Address - Phone:406-756-2555
Mailing Address - Fax:406-756-2558
Practice Address - Street 1:115 COMMONS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1906
Practice Address - Country:US
Practice Address - Phone:406-756-2555
Practice Address - Fax:406-756-2558
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1614PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
60138OtherBCBS PROVIDER NUMBER
MT0348619Medicaid