Provider Demographics
NPI:1104830793
Name:MERCURY STREET MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:MERCURY STREET MEDICAL GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:G
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-723-1300
Mailing Address - Street 1:300 W MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1652
Mailing Address - Country:US
Mailing Address - Phone:406-494-3768
Mailing Address - Fax:406-723-1335
Practice Address - Street 1:3703 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6897
Practice Address - Country:US
Practice Address - Phone:406-494-3768
Practice Address - Fax:406-723-1335
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCURY STREET MEDICAL GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty