Provider Demographics
NPI:1427096585
Name:PROVIDENCE HEALTH & SERVICES MT
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST SECRETARY ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 31001 - 4114
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:SUITE 320
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:406-329-5606
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A207RC0000X, 207RC0001X, 363AM0700X
207RI0011X, 208G00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTD96181Medicare UPIN
MTB48927Medicare UPIN
MTP42324Medicare UPIN
MTB84863Medicare UPIN
MTH09323Medicare UPIN
MTM000080738Medicare PIN
MTD53797Medicare UPIN
MTG27989Medicare UPIN
MTG43572Medicare UPIN
MTB53166Medicare UPIN
MTD96141Medicare UPIN
MTD96262Medicare UPIN
MTG85310Medicare UPIN
MTC34687Medicare UPIN
MTD37535Medicare UPIN
MTD96056Medicare UPIN
MTE28047Medicare UPIN
MTE78605Medicare UPIN
MTG69630Medicare UPIN