Provider Demographics
NPI:1801949722
Name:MORTENSON, DALE R (MD, FACS)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:400 13TH AVE S STE 102
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4300
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7773208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000099960OtherBLUE CROSS BLUE SHIELD
MT020053444OtherRAILROAD MEDICARE
MT608333600OtherUS DEPT OF LABOR
MT0000048433Medicaid
MT0000048433Medicaid
MT020053444OtherRAILROAD MEDICARE
MT000082722Medicare ID - Type Unspecified