Provider Demographics
NPI:1528716370
Name:MALTA MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:MALTA MEDICAL ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-654-2878
Mailing Address - Street 1:PO BOX 1235
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:MT
Mailing Address - Zip Code:59538-1235
Mailing Address - Country:US
Mailing Address - Phone:406-654-2878
Mailing Address - Fax:406-654-2018
Practice Address - Street 1:801 S 3RD ST E RM 304
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:MT
Practice Address - Zip Code:59538-8769
Practice Address - Country:US
Practice Address - Phone:406-654-2878
Practice Address - Fax:406-654-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0028223Medicaid
MT0000922611OtherBLUE CROSS BLUE SHIELD
MTG414566Medicaid
MT0720001Medicaid