Healthcare Provider Details

I. General information

NPI: 1336204189
Provider Name (Legal Business Name): KEITH MCDIVITT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 HOSPITAL CIRCLE BLACKFEET SERVICE UNIT
BROWNING MT
59417-3630
US

IV. Provider business mailing address

114 4TH ST SW
CUT BANK MT
59427-3630
US

V. Phone/Fax

Practice location:
  • Phone: 406-338-6136
  • Fax:
Mailing address:
  • Phone: 406-873-9157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number363LOOOOOX
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: