Provider Demographics
NPI:1619058302
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 ENROLLMENTS
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 3974
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3974
Mailing Address - Country:US
Mailing Address - Phone:406-542-7271
Mailing Address - Fax:406-329-5877
Practice Address - Street 1:902 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2928
Practice Address - Country:US
Practice Address - Phone:406-542-7271
Practice Address - Fax:406-329-5877
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-18
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10606273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT27-S014Medicare Oscar/Certification