=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013074939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN STATES INFECTIOUS DISEASES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 06/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2831 FORT MISSOULA RD SUITE 301
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59804-7479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-327-4405
-----------------------------------------------------
Fax | 406-327-4477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2831 FORT MISSOULA RD SUITE 301
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59804-7479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-327-4405
-----------------------------------------------------
Fax | 406-327-4477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. LESLIE F WHITNEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 406-327-4405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 6612
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------