Healthcare Provider Details

I. General information

NPI: 1972681419
Provider Name (Legal Business Name): JEANNE WILSON STICHT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 WINNE AVE
HELENA MT
59601-4905
US

IV. Provider business mailing address

PO BOX 24102
SEATTLE WA
98124-0102
US

V. Phone/Fax

Practice location:
  • Phone: 406-457-4200
  • Fax:
Mailing address:
  • Phone: 503-372-2740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number8106
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: