Healthcare Provider Details

I. General information

NPI: 1518124379
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES MT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 E COMMERCIAL AVE
ANACONDA MT
59711-2718
US

IV. Provider business mailing address

PO BOX 31001 - 4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5615
  • Fax: 406-563-8601
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENT
Credential:
Phone: 425-358-9786