Healthcare Provider Details

I. General information

NPI: 1306809843
Provider Name (Legal Business Name): ELIZABETH RYAN JAFFE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH RYAN BERGEMANN

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 BURNS WAY
KALISPELL MT
59901-3109
US

IV. Provider business mailing address

1287 BURNS WAY STE 660
KALISPELL MT
59901-3109
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-8120
  • Fax: 406-752-8134
Mailing address:
  • Phone: 406-752-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMED-PHYS-LIC-100641
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number100641
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: