Provider Demographics
NPI:1750557690
Name:CARL THORNBLADE, MD, PLLC
Entity type:Organization
Organization Name:CARL THORNBLADE, MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ALLERGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:THORNBLADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-728-6472
Mailing Address - Street 1:2801 GREAT NORTHERN LOOP STE 101
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1745
Mailing Address - Country:US
Mailing Address - Phone:406-728-6472
Mailing Address - Fax:406-728-9175
Practice Address - Street 1:2801 GREAT NORTHERN LOOP STE 101
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808
Practice Address - Country:US
Practice Address - Phone:406-728-6472
Practice Address - Fax:406-728-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11594207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty