Healthcare Provider Details

I. General information

NPI: 1154562981
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES MT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4096
US

IV. Provider business mailing address

PO BOX 31001 - 4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-1613
  • Fax:
Mailing address:
  • Phone: 406-543-7271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENT
Credential:
Phone: 425-358-9786