Provider Demographics
NPI:1427128495
Name:POWELL COUNTY PHYSICAL THERAPY
Entity type:Organization
Organization Name:POWELL COUNTY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCGILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-846-1991
Mailing Address - Street 1:1101 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722-1806
Mailing Address - Country:US
Mailing Address - Phone:406-846-1991
Mailing Address - Fax:406-846-1347
Practice Address - Street 1:1101 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-1806
Practice Address - Country:US
Practice Address - Phone:406-846-1991
Practice Address - Fax:406-846-1347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0073143OtherMT STATE FUND PROV. #
MT0343720Medicaid
MTMSF 1179681OtherMT STATE FUND GRP. #
MT0073143OtherMT STATE FUND PROV. #
MTCH3180Medicare ID - Type UnspecifiedRR MEDICARE GP. #