Provider Demographics
NPI:1336204189
Name:MCDIVITT, KEITH (NP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CUT BANK
Mailing Address - State:MT
Mailing Address - Zip Code:59427-3630
Mailing Address - Country:US
Mailing Address - Phone:406-873-9157
Mailing Address - Fax:
Practice Address - Street 1:760 HOSPITAL CIRCLE
Practice Address - Street 2:BLACKFEET SERVICE UNIT
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417-3630
Practice Address - Country:US
Practice Address - Phone:406-338-6136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT363LOOOOOX363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP33868Medicare UPIN