Healthcare Provider Details

I. General information

NPI: 1033641550
Provider Name (Legal Business Name): MATTHEW JOSEPH ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 13TH AVE E
POLSON MT
59860-5315
US

IV. Provider business mailing address

PO BOX 12
LIBERTY LAKE WA
99019-0012
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-5680
  • Fax: 406-883-8910
Mailing address:
  • Phone: 866-747-2455
  • Fax: 406-329-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMED-PHYS-LIC-117887
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: