=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629064266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN FOREST SACRY PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 FIRST ST W
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59759-0339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-287-3003
-----------------------------------------------------
Fax | 406-287-3014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 339
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59759-0339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-287-3003
-----------------------------------------------------
Fax | 406-287-3014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 360
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------