Healthcare Provider Details

I. General information

NPI: 1841835113
Provider Name (Legal Business Name): ORIGIN HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 FORT MISSOULA RD STE 232
MISSOULA MT
59804-7479
US

IV. Provider business mailing address

2831 FORT MISSOULA RD STE 232
MISSOULA MT
59804-7479
US

V. Phone/Fax

Practice location:
  • Phone: 406-523-5650
  • Fax: 406-303-4041
Mailing address:
  • Phone: 406-523-5650
  • Fax: 406-303-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN G LOOSLI
Title or Position: EXECUTIVE DIRECTOR
Credential: MSC
Phone: 208-557-9898