1649277799 NPI number — BIGFORK PHYSICAL THERAPY & SPORTS REHABILITATION INC

Table of content: (NPI 1649277799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649277799 NPI number — BIGFORK PHYSICAL THERAPY & SPORTS REHABILITATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIGFORK PHYSICAL THERAPY & SPORTS REHABILITATION INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MICHAEL J. CLOSE, RPT
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649277799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1527
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIGFORK
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59911-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-837-6892
Provider Business Mailing Address Fax Number:
406-837-6435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6400 MT HWY 35
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIGFORK
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-837-6892
Provider Business Practice Location Address Fax Number:
406-837-6435
Provider Enumeration Date:
07/05/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLOSE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JON
Authorized Official Title or Position:
OWNER PHYSICAL THERAPIST
Authorized Official Telephone Number:
406-837-6892

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  1350PT , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000345185 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61996 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".