Healthcare Provider Details

I. General information

NPI: 1750557690
Provider Name (Legal Business Name): CARL THORNBLADE, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 GREAT NORTHERN LOOP STE 101
MISSOULA MT
59808
US

IV. Provider business mailing address

2801 GREAT NORTHERN LOOP STE 101
MISSOULA MT
59808-1745
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-6472
  • Fax: 406-728-9175
Mailing address:
  • Phone: 406-728-6472
  • Fax: 406-728-9175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number11594
License Number StateMT

VIII. Authorized Official

Name: DR. CARL EDWARD THORNBLADE
Title or Position: ALLERGIST/OWNER
Credential: MD
Phone: 406-728-6472