Healthcare Provider Details

I. General information

NPI: 1215222617
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES MT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
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
59802-4008
US

IV. Provider business mailing address

PO BOX 31001 - 4114
PASADENA CA
91110-4114
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL
# 14
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number StateNULL
# 15
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

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