1649277567 NPI number — BLAINE STIMAC PT,MS

Table of content: BLAINE STIMAC PT,MS (NPI 1649277567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649277567 NPI number — BLAINE STIMAC PT,MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STIMAC
Provider First Name:
BLAINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT,MS
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:
1649277567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 COMMONS WAY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59901-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-756-2555
Provider Business Mailing Address Fax Number:
406-756-2558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 COMMONS WAY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-756-2555
Provider Business Practice Location Address Fax Number:
406-756-2558
Provider Enumeration Date:
07/07/2005

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: 225100000X , with the licence number:  1614PT , 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: 60138 . This is a "BCBS PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0348619 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".