Healthcare Provider Details

I. General information

NPI: 1265477913
Provider Name (Legal Business Name): SEELEY SWAN MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 MT HIGHWAY 83 N
SEELEY LAKE MT
59868-1380
US

IV. Provider business mailing address

PO BOX 7666
MISSOULA MT
59807-7666
US

V. Phone/Fax

Practice location:
  • Phone: 406-677-2277
  • Fax: 406-677-2387
Mailing address:
  • Phone: 406-721-5600
  • Fax: 406-721-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11319
License Number StateMT

VIII. Authorized Official

Name: JYOCE STEVENS
Title or Position: DIR OF ANCILLARY & SATELLITE SVS
Credential:
Phone: 406-721-5600