MEDICARE: MISSOULA COMMUNITY HEALTH SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1073080461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOULA COMMUNITY HEALTH SERVICES, INC

Provider Business Mailing Address
First Line	:	PO BOX 66
Second Line	:
City	:	SUPERIOR
State	:	MT
Zip	:	59872-0066
Country	:	US
Telephone Number	:	406-822-4841
Fax Number	:	406-822-4963

Provider Business Practice Location Address
First Line	:	1208 6TH AVE
Second Line	:
City	:	SUPERIOR
State	:	MT
Zip	:	59872-9667
Country	:	US
Telephone Number	:	406-822-4841
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	STACY CONROW-VERVERIS
Credential	:
Telephone Number	:	406-822-4841

Provider Enumeration Date	:	10/24/2018
Last Update Date	:	10/12/2022

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