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General NPI Number Information
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NPI Number | 1063653897
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Entity Type | Organization
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Legal Business Name | PROVIDENCE HEALTH & SERVICES MT
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Dates
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Enumeration Date | 03/06/2009
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 500 W BROADWAY ST 3RD FLOOR
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City | MISSOULA
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State | MT
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Zip | 59802-4096
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Country | US
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Telephone | 406-327-1670
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 31001 - 4114
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City | PASADENA
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State | CA
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Zip | 91110-4114
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Country | US
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Telephone | 406-327-1918
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Fax |
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Authorized Official
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Title or Position | ASSISTANT SECRETARY ENROLLMENT
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Name | DONALD W ANDERSON JR.
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Credential |
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Telephone | 425-358-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2081P0004X
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Taxonomy Name | Spinal Cord Injury Medicine Physician
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License Number |
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License Number State |
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