Provider Demographics
NPI:1992849525
Name:MISSOULA PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:MISSOULA PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:G
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-543-4890
Mailing Address - Street 1:1805 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5781
Mailing Address - Country:US
Mailing Address - Phone:406-543-4890
Mailing Address - Fax:406-543-4892
Practice Address - Street 1:1805 BANCROFT ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5781
Practice Address - Country:US
Practice Address - Phone:406-543-4890
Practice Address - Fax:406-543-4892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT218PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1992849525Medicaid