PROVIDENCE MEDICAL GROUP MONTANA – Family Medicine Physician, NPI 1215222617
Family Medicine Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for PROVIDENCE MEDICAL GROUP MONTANA
PO BOX 12
LIBERTY LAKE, WA 990190012
Phone: (406) 543-7271
Type: Mailing
PO BOX 31001 - 4114
PASADENA, CA 911104114
Phone:
Type: Mailing
500 W BROADWAY ST
MISSOULA, MT 598024008
Phone: (406) 543-7271
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2025-10-16
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2025-11-30 (192 days ago).
Enrollment records
24
Earliest due date
2025-11-30
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20031229000787 | O | Clinic/Group Practice | MT | TBD |
| O20101227000036 | O | Clinic/Group Practice | ID | TBD |
| O20190116003053 | O | Clinic/Group Practice | CO | TBD |
| O20190125001690 | O | Clinic/Group Practice | OR | 2025-11-30 |
| O20190128001139 | O | Clinic/Group Practice | WA | 2025-11-30 |
| O20190129003961 | O | Clinic/Group Practice | AK | 2025-12-31 |
| O20190508002635 | O | Clinic/Group Practice | CA | 2026-01-31 |
| O20200824000195 | O | Clinic/Group Practice | FL | 2026-06-30 |
| O20200831001817 | O | Clinic/Group Practice | MO | 2026-08-31 |
| O20200917000431 | O | Clinic/Group Practice | MI | 2026-09-30 |
| O20200923001208 | O | Clinic/Group Practice | DC | 2026-10-31 |
| O20201002001305 | O | Clinic/Group Practice | HI | TBD |
| O20201008002086 | O | Clinic/Group Practice | NV | TBD |
| O20210107000846 | O | Clinic/Group Practice | NY | TBD |
| O20210713001811 | O | Clinic/Group Practice | TX | TBD |
| O20230206000159 | O | Clinic/Group Practice | MN | TBD |
| O20230310000411 | O | Clinic/Group Practice | AZ | TBD |
| O20240118004347 | O | Clinic/Group Practice | IL | TBD |
| O20240906001372 | O | Clinic/Group Practice | NE | TBD |
| O20240910002148 | O | Clinic/Group Practice | WI | TBD |
| O20250305000754 | O | Clinic/Group Practice | UT | TBD |
| O20250721002882 | O | Clinic/Group Practice | NC | TBD |
| O20251013004133 | O | Clinic/Group Practice | NJ | TBD |
| O20251016002731 | O | Clinic/Group Practice | TN | TBD |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 99019)
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