Healthcare Provider Details

I. General information

NPI: 1669892576
Provider Name (Legal Business Name): CASEY AMBROSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5635
  • Fax:
Mailing address:
  • Phone: 406-327-1918
  • Fax: 406-549-2246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2014-0357
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMED-PHYS-LIC-53219
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number53219
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: