MEDICARE: MR. BLAISE EMILE FAVARA MD

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	208000000X	Pediatrics Physician	MT7843	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10341	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386637676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BLAISE EMILE FAVARA MD

Provider Business Mailing Address
First Line	:	1114 W MAIN
Second Line	:	SOUTH VALLEY PEDIATRICS
City	:	HAMILTON
State	:	MT
Zip	:	59840
Country	:	US
Telephone Number	:	406-363-5013
Fax Number	:	406-363-3714

Provider Business Practice Location Address
First Line	:	1114 W MAIN
Second Line	:	SOUTH VALLEY PEDIATRICS
City	:	HAMILTON
State	:	MT
Zip	:	59840
Country	:	US
Telephone Number	:	406-363-5013
Fax Number	:	406-363-3714

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	09/26/2007

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