Provider Demographics
NPI:1538230271
Name:MEDA, BRENTON ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:ARTHUR
Last Name:MEDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5202
Mailing Address - Country:US
Mailing Address - Phone:406-315-3398
Mailing Address - Fax:406-315-3400
Practice Address - Street 1:2619 16TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5202
Practice Address - Country:US
Practice Address - Phone:406-315-3398
Practice Address - Fax:406-315-3400
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9567207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0028171Medicaid
MT000081742Medicare PIN
MT220029966Medicare PIN
H27626Medicare UPIN