=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184876534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEELEY SWAN MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 10/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6287 MT HIGHWAY 83 MILE MARKER 38 AND 39
-----------------------------------------------------
City | CONDON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59826-8702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-754-2240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7666
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59807-7666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR OF ANCILLARY & SATELLITE SVS
-----------------------------------------------------
Name | JOYCE E STEVENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-721-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------