NPIMap

Organization Active NPI

Wellspring Health and Aesthetics PLLC

  • Plastic Surgery Physician
  • Missoula, MT
National Provider Identifier
1487339750
Registry record updated Oct 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Plastic Surgery PhysicianTaxonomy code 208200000X
Legal business name
WELLSPRING HEALTH AND AESTHETICS PLLC
Practice address
500 W Broadway St FL 4
Missoula, MT 59802-4008
Phone
(406) 370-1600
Fax
(406) 493-0333
NPI assigned
Jun 15, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 6, 2023

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

Authorized official

Name
Dr. Stephanie Suprenant, MDNPI 1508122938
Title
Plastic and Reconstructive Surgeon
Phone
(406) 370-1600

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Plastic Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 208200000X Primary
Plastic Surgery Within the Head and Neck (Plastic Surgery) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2082S0099X
Surgery of the Hand (Plastic Surgery) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2082S0105X
Plastic and Reconstructive Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2086S0122X

Addresses

Primary practice location

500 W Broadway St FL 4
Missoula, MT 59802-4008

Mailing address

122 Daly Ave
Missoula, MT 59801-4212
Phone (815) 482-9859

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230920000697 MT Part B Supplier - Clinic/Group Practice 6709240096 Receives reassigned benefits from 2 practitioners
Practice locations: Missoula, MT

National Provider Directory

National Provider Directory

Locations

1802 Dearborn Ave
Missoula, MT 59801

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1686787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696550400000",
    "number": "1487339750",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "122 DALY AVE",
            "city": "MISSOULA",
            "state": "MT",
            "postal_code": "598014212",
            "telephone_number": "815-482-9859"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 W BROADWAY ST FL 4",
            "city": "MISSOULA",
            "state": "MT",
            "postal_code": "598024008",
            "telephone_number": "406-370-1600",
            "fax_number": "406-493-0333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSPRING HEALTH AND AESTHETICS PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-06-15",
        "last_updated": "2023-10-06",
        "certification_date": "2023-10-06",
        "status": "A",
        "authorized_official_last_name": "SUPRENANT",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_title_or_position": "PLASTIC AND RECONSTRUCTIVE SURGEON",
        "authorized_official_telephone_number": "406-370-1600",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208200000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Plastic Surgery",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2082S0099X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Plastic Surgery, Plastic Surgery Within the Head and Neck",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2082S0105X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Plastic Surgery, Surgery of the Hand",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2086S0122X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery, Plastic and Reconstructive Surgery",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Oct 6, 2023; 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.