=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790931517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HEALTH & SERVICES MT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2008
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3075 N RESERVE ST SUITE Q
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-1390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-327-1850
-----------------------------------------------------
Fax | 406-327-1875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31001 - 4114
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY ENROLLMENT
-----------------------------------------------------
Name | MR. DONALD W ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-358-9786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------