Healthcare Provider Details

I. General information

NPI: 1174609432
Provider Name (Legal Business Name): CHARLES O ALLEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 TOWN CENTER AVE
BIG SKY MT
59716-1713
US

IV. Provider business mailing address

915 HIGHLAND BLVD
BOZEMAN MT
59715-6902
US

V. Phone/Fax

Practice location:
  • Phone: 406-995-6995
  • Fax:
Mailing address:
  • Phone: 406-414-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number67187
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: