Provider Demographics
NPI:1932217114
Name:RAVALLI ORTHOPEDICS & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:RAVALLI ORTHOPEDICS & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-363-2391
Mailing Address - Street 1:312 FAIR GROUNDS ROAD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840
Mailing Address - Country:US
Mailing Address - Phone:406-361-7680
Mailing Address - Fax:406-363-4060
Practice Address - Street 1:312 FAIR GROUNDS ROAD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840
Practice Address - Country:US
Practice Address - Phone:406-361-7680
Practice Address - Fax:406-363-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8555207X00000X
MT207X00000X
MT0292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0157658Medicaid
MT0157658Medicaid