1649277799 NPI number — BIGFORK PHYSICAL THERAPY & SPORTS REHABILITATION INC

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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".




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