Provider Demographics
NPI:1700762200
Name:MISSOULA SPORTS MEDICINE AND IMAGING LLC
Entity type:Organization
Organization Name:MISSOULA SPORTS MEDICINE AND IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-540-4117
Mailing Address - Street 1:1510 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4756
Mailing Address - Country:US
Mailing Address - Phone:406-540-4117
Mailing Address - Fax:
Practice Address - Street 1:1510 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4756
Practice Address - Country:US
Practice Address - Phone:406-540-4117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty