Provider Demographics
NPI:1780883611
Name:BRIAN D. MCCOLLOM, O.D., INC.
Entity type:Organization
Organization Name:BRIAN D. MCCOLLOM, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCOLLOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-466-2802
Mailing Address - Street 1:913 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CHOTEAU
Mailing Address - State:MT
Mailing Address - Zip Code:59422-9123
Mailing Address - Country:US
Mailing Address - Phone:406-466-2802
Mailing Address - Fax:406-466-2732
Practice Address - Street 1:913 4TH ST NW
Practice Address - Street 2:
Practice Address - City:CHOTEAU
Practice Address - State:MT
Practice Address - Zip Code:59422-9123
Practice Address - Country:US
Practice Address - Phone:406-466-2802
Practice Address - Fax:406-466-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0482817Medicaid
MT000085175Medicare PIN
MT000085176Medicare PIN
MT0482817Medicaid
MT6053100001Medicare NSC