Healthcare Provider Details

I. General information

NPI: 1770143653
Provider Name (Legal Business Name): OWEN L MAYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

PO BOX 94484
SEATTLE WA
98124-6784
US

V. Phone/Fax

Practice location:
  • Phone: 425-407-1500
  • Fax:
Mailing address:
  • Phone: 425-407-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number120508
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: