Provider Demographics
NPI:1043294572
Name:LAINE, TED B (MD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:B
Last Name:LAINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 FORT MISSOULA RD
Mailing Address - Street 2:STE 201
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7420
Mailing Address - Country:US
Mailing Address - Phone:406-721-5566
Mailing Address - Fax:406-728-1868
Practice Address - Street 1:2825 FORT MISSOULA RD
Practice Address - Street 2:STE 201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7420
Practice Address - Country:US
Practice Address - Phone:406-721-5566
Practice Address - Fax:406-728-1868
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT4247174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT005-6472Medicaid
WA1383801Medicaid
MT12790OtherBLUE CROSS/BLUE SHIELD
MT005-6472Medicaid
MTD-96207Medicare UPIN