Provider Demographics
NPI:1699916429
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 FOR 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 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:406-327-3260
Mailing Address - Fax:
Practice Address - Street 1:601 W SPRUCE ST STE J
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4047
Practice Address - Country:US
Practice Address - Phone:406-327-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-06
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN