Healthcare Provider Details

I. General information

NPI: 1609932037
Provider Name (Legal Business Name): MICHAEL JON CLOSE RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HOLT DRIVE
BIGFORK MT
59911
US

IV. Provider business mailing address

PO BOX 1527
BIGFORK MT
59911-1527
US

V. Phone/Fax

Practice location:
  • Phone: 406-837-6892
  • Fax: 406-837-6435
Mailing address:
  • Phone: 406-837-6892
  • Fax: 406-837-6435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1350PT
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier61996
Identifier TypeOTHER
Identifier StateMT
Identifier IssuerBCBS OF MONTANA PROVIDER
# 2
Identifier0000345185
Identifier TypeMEDICAID
Identifier StateMT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: