Healthcare Provider Details

I. General information

NPI: 1699916429
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: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W SPRUCE ST STE J
MISSOULA MT
59802-4047
US

IV. Provider business mailing address

PO BOX 31001 - 4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-3350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

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