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General NPI Number Information
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NPI Number | 1083578314
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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 | 12/11/2025
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Last Update Date | 12/11/2025
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Provider Practice Location Address
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Address Line | 3017 PAXSON STREET
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City | MISSOULA
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State | MT
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Zip | 59801
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Country | US
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Telephone | 406-519-3422
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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 |
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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 WAYNE 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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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