Healthcare Provider Details

I. General information

NPI: 1316989544
Provider Name (Legal Business Name): MISSOULA RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4003
US

IV. Provider business mailing address

3205 S RUSSELL ST
MISSOULA MT
59801-8536
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-7271
  • Fax:
Mailing address:
  • Phone: 406-721-4906
  • Fax: 406-541-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK W ELLIOTT
Title or Position: PARTNER
Credential: M.D.
Phone: 406-721-4906