Healthcare Provider Details

I. General information

NPI: 1215111679
Provider Name (Legal Business Name): STEPHEN D SMITH MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 FORT MISSOULA RD 115
MISSOULA MT
59804-7420
US

IV. Provider business mailing address

2825 FORT MISSOULA RD 115
MISSOULA MT
59804-7420
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-4292
  • Fax: 406-728-5770
Mailing address:
  • Phone: 406-728-4292
  • Fax: 406-728-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4309
License Number StateMT

VIII. Authorized Official

Name: SHANNON L CHAPLA
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-728-4292