Healthcare Provider Details

I. General information

NPI: 1316053895
Provider Name (Legal Business Name): ERIC E TREVELLINE MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 FT MISSOULA RD STE 303
MISSOULA MT
59804-7401
US

IV. Provider business mailing address

2831 FT MISSOULA RD STE 303
MISSOULA MT
59804-7401
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-4685
  • Fax: 406-327-4785
Mailing address:
  • Phone: 406-327-4685
  • Fax: 406-327-4785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number10322
License Number StateMT

VIII. Authorized Official

Name: ERIC E TREVELLINE
Title or Position: OWNER/M.D.
Credential: MD
Phone: 406-327-4685