Healthcare Provider Details

I. General information

NPI: 1720222508
Provider Name (Legal Business Name): BRENT MUIR ROSTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 MULLAN RD STE C
MISSOULA MT
59808-1811
US

IV. Provider business mailing address

2360 MULLAN RD, STE C
MISSOULA MT
59808-1811
US

V. Phone/Fax

Practice location:
  • Phone: 406-721-4436
  • Fax: 406-721-6053
Mailing address:
  • Phone: 406-721-4436
  • Fax: 406-721-6053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberMD158161
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberA130888
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number15371
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberMED-PHYS-LIC-36762
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: