1144260514 NPI number — INFECTIOUS DISEASE SPECIALISTS, PC

Table of content: (NPI 1144260514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144260514 NPI number — INFECTIOUS DISEASE SPECIALISTS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASE SPECIALISTS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144260514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8897
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59807-8897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-721-6221
Provider Business Mailing Address Fax Number:
406-721-6221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
614 W SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59802-4002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-327-1666
Provider Business Practice Location Address Fax Number:
406-329-5606
Provider Enumeration Date:
06/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRAIG
Authorized Official First Name:
WILLA
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
406-721-6221

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  6638 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0154581 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00185637 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1073553491 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 92275 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".