Healthcare Provider Details

I. General information

NPI: 1700762200
Provider Name (Legal Business Name): MISSOULA SPORTS MEDICINE AND IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S RESERVE ST
MISSOULA MT
59801-4756
US

IV. Provider business mailing address

1510 S RESERVE ST
MISSOULA MT
59801-4756
US

V. Phone/Fax

Practice location:
  • Phone: 406-540-4117
  • Fax:
Mailing address:
  • Phone: 406-540-4117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY J MCCUE
Title or Position: OWNER/PHYSICIAN
Credential:
Phone: 406-540-4117