NPIMap

Individual provider Active NPI

Mallory Koula, MD

  • Family Medicine Physician
  • Missoula, MT
National Provider Identifier
1467987727
Registry record updated Sep 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
MED-PHYS-LIC-114887 Issued in MT
Practice address
3075 N Reserve St Ste Q
Missoula, MT 59808-1390
Phone
(406) 327-1850
Fax
(406) 327-1875
NPI assigned
Apr 25, 2017
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Sep 27, 2022

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 10983218-1205 UT
Family Medicine Physician 207Q00000X MED-PHYS-LIC-114887 MT Primary

Addresses

Primary practice location

3075 N Reserve St Ste Q
Missoula, MT 59808-1390

Mailing address

PO Box 12
Liberty Lake, WA 99019-0012
Phone (406) 327-1850

Other practice location 1

30 N 1900 E Rm 1A071
Salt Lake City, UT 84132-0002
Phone (801) 581-2121

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MT
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20221007002383 MT Practitioner - Family Practice 6507110509 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Medical College of Wisconsin, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Providence Health and Services MtGroup PAC ID 6608786306, 358 clinicians

Practice addresses (Care Compare)

3075 N Reserve St
Suite Q
Missoula, MT 59808-1390
Phone (406) 327-1850

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MED-PHYS-LIC-114887MTMDFamily Medicine Physician
10983218-1205UTMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Mt Current Accepting new patients
Providence Health & Services Mt Family Medicine CurrentSince Nov 5, 2022 Accepting new patients
Providence Health & Services Mt CurrentSince Nov 5, 2022 Accepting new patients
Providence Health & Services Mt Past Accepting new patients

Locations

3075 N Reserve St
Ste Q
Missoula, MT 59808
Phone (406) 327-1750

500 W Broadway St
Missoula, MT 59802
Phone (406) 327-1918

500 W Broadway St
Ste 320
Missoula, MT 59802
Phone (406) 329-2945

Interoperability endpoints

  • Direct secure messaging: mkoula805702@wm.providencedirect.org

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1493078400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664236800000",
    "number": "1467987727",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 12",
            "city": "LIBERTY LAKE",
            "state": "WA",
            "postal_code": "990190012",
            "telephone_number": "406-327-1850",
            "fax_number": "406-327-1875"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3075 N RESERVE ST STE Q",
            "city": "MISSOULA",
            "state": "MT",
            "postal_code": "598081390",
            "telephone_number": "406-327-1850",
            "fax_number": "406-327-1875"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "30 N 1900 E Rm 1A071",
            "address_purpose": "LOCATION",
            "city": "Salt Lake City",
            "state": "UT",
            "postal_code": "841320002",
            "country_code": "US",
            "telephone_number": "801-581-2121",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KOULA",
        "first_name": "MALLORY",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-04-25",
        "last_updated": "2022-09-27",
        "certification_date": "2022-09-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "UT",
            "license": "10983218-1205",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MT",
            "license": "MED-PHYS-LIC-114887",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Missoula, MT

Sources for this page

Verify at the official NPI Registry.