Healthcare Provider Details

I. General information

NPI: 1104830793
Provider Name (Legal Business Name): MERCURY STREET MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 HARRISON AVE
BUTTE MT
59701-6897
US

IV. Provider business mailing address

300 W MERCURY ST
BUTTE MT
59701-1652
US

V. Phone/Fax

Practice location:
  • Phone: 406-494-3768
  • Fax: 406-723-1335
Mailing address:
  • Phone: 406-494-3768
  • Fax: 406-723-1335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT G BUTLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 406-723-1300