MEDICARE: STATE OF MONTANA

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	2084N0400X	Neurology Physician
2	2084P0800X	Psychiatry Physician
3	2084P0802X	Addiction Psychiatry Physician
4	324500000X	Substance Abuse Rehabilitation Facility	10324	MT

Other Identifiers

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

General Provider Information

NPI Number	:	1497765150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MONTANA

Provider Business Mailing Address
First Line	:	111 N SANDERS ST DEPT 30
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59601-4520
Country	:	US
Telephone Number	:	406-444-3416
Fax Number	:	406-444-3082

Provider Business Practice Location Address
First Line	:	525 E MERCURY ST
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-1911
Country	:	US
Telephone Number	:	406-496-5407
Fax Number	:	406-496-5437

Authorized Official
Title or Position	:	FACILITY REIMBURSEMENT MANAGER
Name	:	MRS. ALEASHA MARTIN
Credential	:
Telephone Number	:	406-444-3416

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	02/26/2024

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Directions to “STATE OF MONTANA ” Practice Location

Language	Start Address	Practice Location

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