Healthcare Provider Details

I. General information

NPI: 1316993082
Provider Name (Legal Business Name): GORDON D. STILLIE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 SUNNYVIEW LN
KALISPELL MT
59901-3156
US

IV. Provider business mailing address

PO BOX 7653
KALISPELL MT
59904-0653
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-1790
  • Fax:
Mailing address:
  • Phone: 406-751-6948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number10467
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: