Healthcare Provider Details

I. General information

NPI: 1467894121
Provider Name (Legal Business Name): BENJAMIN D GRASS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 6TH AVE SW
RONAN MT
59864-2634
US

IV. Provider business mailing address

PO BOX 12
LIBERTY LAKE WA
99019-0012
US

V. Phone/Fax

Practice location:
  • Phone: 406-676-4441
  • Fax: 406-676-0835
Mailing address:
  • Phone: 866-747-2455
  • Fax: 406-676-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50100
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: