Healthcare Provider Details

I. General information

NPI: 1477661874
Provider Name (Legal Business Name): ALLERGY AND INFUSION SERVICES OF MISSOULA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 FORT MISSOULA RD SUITE 317C
MISSOULA MT
59804-7420
US

IV. Provider business mailing address

2825 FORT MISSOULA RD SUITE 317C
MISSOULA MT
59804-7420
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-5428
  • Fax: 406-728-5458
Mailing address:
  • Phone: 406-728-5428
  • Fax: 406-728-5458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number7276
License Number StateMT

VIII. Authorized Official

Name: WARD S DEWITT
Title or Position: OWNER/MD
Credential: MD
Phone: 406-728-5428