Provider Demographics
NPI:1386710879
Name:OSTERTAG, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:OSTERTAG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 SKAGGS BUILDING
Mailing Address - Street 2:U OF M, DEPT. OF PHYSICAL THERAPY, ROOM 025
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59812-0001
Mailing Address - Country:US
Mailing Address - Phone:406-243-4016
Mailing Address - Fax:406-243-2795
Practice Address - Street 1:135 SKAGGS BUILDING
Practice Address - Street 2:U OF M, DEPT. OF PHYSICAL THERAPY, ROOM 025
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0001
Practice Address - Country:US
Practice Address - Phone:406-243-4016
Practice Address - Fax:406-243-2795
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT1271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3401785Medicaid
MT61161OtherBLUE CROSS BLUE SHIELD