Healthcare Provider Details

I. General information

NPI: 1821235599
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES MT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2009
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 WESTWOOD DR
HAMILTON MT
59840-2342
US

IV. Provider business mailing address

PO BOX 34439
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 406-363-4209
  • Fax: 406-363-4356
Mailing address:
  • Phone: 406-363-4209
  • Fax: 406-363-4356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERI MASTERS
Title or Position: RCM OPERATIONS MGR.
Credential:
Phone: 406-329-5795