NPIMap

Organization Active NPI

Providence Health & Services Mt

Doing business as Providence Medical Group Montana

  • Obesity Medicine (Internal Medicine) Physician
  • Missoula, MT
National Provider Identifier
1124268982
Registry record updated May 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obesity Medicine (Internal Medicine) PhysicianTaxonomy code 207RB0002X
Legal business name
PROVIDENCE HEALTH & SERVICES MT
Doing business as
Providence Medical Group Montana
Practice address
500 W Broadway St
4TH Floor
Missoula, MT 59802-4096
Phone
(406) 329-5866
NPI assigned
Mar 5, 2009
Last updated
May 6, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH & SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 6, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Assistant Secretary Enrollments
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Obesity Medicine (Internal Medicine) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RB0002X Primary

Addresses

Primary practice location

500 W Broadway St
4TH Floor
Missoula, MT 59802-4096

Mailing address

PO Box 31001 - 4114
Pasadena, CA 91110-4114
Phone (406) 329-5866

Other names 2

  • PROVIDENCE MEDICAL GROUP MONTANA Doing business as
  • PMG MT Bariatric Services Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031229000787 MT Part B Supplier - Clinic/Group Practice 6608786306 Receives reassigned benefits from 382 practitioners
This NPI is an additional NPI on the enrollment
Practice locations: Missoula, MT; Plains, MT; Polson, MT; St Ignatius, MT; Stevensville, MT; Anaconda, MT; Butte, MT; Corvallis, MT…

National Provider Directory

National Provider Directory
Tax ID family
St Patrick Hospital Corp39 organizations share this tax ID, including this one
Part of
Providence Service Corporation

Other organizations with this tax ID 38

Organizations that report the same tax identification number in the National Provider Directory.

View all 38

Locations

500 W Broadway St
#A
Missoula, MT 59802

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1236211200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746489600000",
    "number": "1124268982",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001 - 4114",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104114",
            "telephone_number": "406-329-5866"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 W BROADWAY ST",
            "address_2": "4TH FLOOR",
            "city": "MISSOULA",
            "state": "MT",
            "postal_code": "598024096",
            "telephone_number": "406-329-5866"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES MT",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES",
        "enumeration_date": "2009-03-05",
        "last_updated": "2025-05-06",
        "certification_date": "2025-05-06",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207RB0002X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Obesity Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP MONTANA",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PMG MT Bariatric Services",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Missoula, MT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.