Healthcare Provider Details

I. General information

NPI: 1811215106
Provider Name (Legal Business Name): CORY D JURGENSMEIER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 03/07/2023
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 STOCKYARD RD STE I-200
MISSOULA MT
59808-1548
US

IV. Provider business mailing address

PO BOX 1847
GILBERT AZ
85299-1847
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-8420
  • Fax:
Mailing address:
  • Phone: 480-507-2961
  • Fax: 480-507-2971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number49022
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMED-PHYS-LIC-89802
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: