Healthcare Provider Details

I. General information

NPI: 1639203920
Provider Name (Legal Business Name): ST JOSEPH ORTHOPEDIC AND SPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 13TH AVE E
POLSON MT
59860-5315
US

IV. Provider business mailing address

6 13TH AVE E
POLSON MT
59860-5315
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-5377
  • Fax:
Mailing address:
  • Phone: 406-883-5377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10617
License Number StateMT

VIII. Authorized Official

Name: JOHN GLUECKERT
Title or Position: CEO
Credential:
Phone: 406-883-8416