Healthcare Provider Details

I. General information

NPI: 1821327008
Provider Name (Legal Business Name): MARK IBSEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 NEILL AVE
HELENA MT
59601-3330
US

IV. Provider business mailing address

39 NEILL AVE
HELENA MT
59601-3330
US

V. Phone/Fax

Practice location:
  • Phone: 406-513-1052
  • Fax: 406-513-1054
Mailing address:
  • Phone: 406-513-1052
  • Fax: 406-513-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number7378
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7378
License Number StateMT

VIII. Authorized Official

Name: DR. MARK S IBSEN
Title or Position: OWNER
Credential: M.D.
Phone: 406-513-1052