Provider Demographics
NPI:1720067705
Name:FIVE VALLEYS UROLOGY
Entity Type:Organization
Organization Name:FIVE VALLEYS UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-728-3366
Mailing Address - Street 1:2875 TINA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808
Mailing Address - Country:US
Mailing Address - Phone:406-728-3366
Mailing Address - Fax:406-329-2896
Practice Address - Street 1:2875 TINA
Practice Address - Street 2:SUITE 101
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1308
Practice Address - Country:US
Practice Address - Phone:406-728-3366
Practice Address - Fax:406-329-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT6221290001Medicare NSC