NPIMap

Organization Active NPI

Providence Health & Services Mt

Doing business as PMG MT Grant Creek Family Med

  • Family Medicine Physician
  • Missoula, MT
National Provider Identifier
1790931517
Registry record updated May 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PROVIDENCE HEALTH & SERVICES MT
Doing business as
PMG MT Grant Creek Family Med
Providence Medical Group Montana
Practice address
3075 N Reserve St
Suite Q
Missoula, MT 59808-1390
Phone
(406) 327-1850
Fax
(406) 327-1875
NPI assigned
Aug 12, 2008
Last updated
May 7, 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 7, 2025

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

Authorized official

Name
Mr. Donald W Anderson Jr.
Title
Assistant Secretary Enrollment
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

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

Mailing address

PO Box 31001 - 4114
Pasadena, CA 91110-4114

Other identifiers 1

IdentifierTypeStateIssuer
8445OtherMTMEDICAL LICENSE NUMBER

Other names 2

  • PMG MT Grant Creek Family Med Doing business as
  • PROVIDENCE MEDICAL GROUP MONTANA Doing business as

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
Part of
Providence Service Corporation

Locations

3075 N Reserve St
Missoula, MT 59808
Phone (406) 721-4646

902 N Orange St
Ste 303
Missoula, MT 59802

110 W Cliff Dr
Spokane, WA 99204
Phone (509) 370-8239

Practitioners & affiliated clinicians

Practitioners 10

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": "1218499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746576000000",
    "number": "1790931517",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3075 N RESERVE ST",
            "address_2": "SUITE Q",
            "city": "MISSOULA",
            "state": "MT",
            "postal_code": "598081390",
            "telephone_number": "406-327-1850",
            "fax_number": "406-327-1875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES MT",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES",
        "enumeration_date": "2008-08-12",
        "last_updated": "2025-05-07",
        "certification_date": "2025-05-07",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENT",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE NUMBER",
            "identifier": "8445",
            "state": "MT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PMG MT Grant Creek Family Med",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PROVIDENCE MEDICAL GROUP MONTANA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 7, 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.