=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750557690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARL THORNBLADE, MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2008
-----------------------------------------------------
Last Update Date | 02/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 GREAT NORTHERN LOOP STE 101
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-728-6472
-----------------------------------------------------
Fax | 406-728-9175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 GREAT NORTHERN LOOP STE 101
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-1745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-728-6472
-----------------------------------------------------
Fax | 406-728-9175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ALLERGIST/OWNER
-----------------------------------------------------
Name | DR. CARL EDWARD THORNBLADE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 406-728-6472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | 11594
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------