Healthcare Provider Details

I. General information

NPI: 1609064013
Provider Name (Legal Business Name): MISSOULA UROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 FORT MISSOULA RD SUITE 201
MISSOULA MT
59804-7423
US

IV. Provider business mailing address

2835 FORT MISSOULA RD SUITE 201
MISSOULA MT
59804-7423
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-1967
  • Fax: 406-543-5379
Mailing address:
  • Phone: 406-543-1967
  • Fax: 406-543-5379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberG47576
License Number StateMT

VIII. Authorized Official

Name: DR. WILLIAM J GRABER
Title or Position: OWNER
Credential: MD
Phone: 406-543-1967