1205194727 NPI number — DR. LAWRENCE G KETTWICH M.D.

Table of content: DR. LAWRENCE G KETTWICH M.D. (NPI 1205194727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205194727 NPI number — DR. LAWRENCE G KETTWICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTWICH
Provider First Name:
LAWRENCE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1205194727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 STOCKYARD RD
Provider Second Line Business Mailing Address:
BLDG I-200
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-728-8420
Provider Business Mailing Address Fax Number:
406-541-8430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 STOCKYARD RD STE I-200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59808-1548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-728-8420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  MD2016-0071 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: MED-PHYS-LIC-55728 , 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: MED-PHYS-LIC-55728 . This is a "MONTANA MEDICAL LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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