Provider Demographics
NPI:1144260514
Name:INFECTIOUS DISEASE SPECIALISTS, PC
Entity type:Organization
Organization Name:INFECTIOUS DISEASE SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:406-721-6221
Mailing Address - Street 1:PO BOX 8897
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-8897
Mailing Address - Country:US
Mailing Address - Phone:406-721-6221
Mailing Address - Fax:406-721-6221
Practice Address - Street 1:614 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4002
Practice Address - Country:US
Practice Address - Phone:406-327-1666
Practice Address - Fax:406-329-5606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6638207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0154581Medicaid
P00185637OtherRR MEDICARE
MT1073553491Medicaid
92275OtherBCBS
MT0154581Medicaid