Provider Demographics
NPI:1598064628
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:ASSISTANT SECRETARY ENROLLMENTS
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 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:406-329-2945
Mailing Address - Fax:406-329-2938
Practice Address - Street 1:601 W SPRUCE ST
Practice Address - Street 2:SUITE A
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4057
Practice Address - Country:US
Practice Address - Phone:406-329-2945
Practice Address - Fax:406-329-2938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-15
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN