Healthcare Provider Details

I. General information

NPI: 1679510101
Provider Name (Legal Business Name): GLENDA WICKSTROM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N 25TH ST SUITE 201
BILLINGS MT
59101-1328
US

IV. Provider business mailing address

315 N 25TH ST SUITE 201
BILLINGS MT
59101-1314
US

V. Phone/Fax

Practice location:
  • Phone: 406-237-4050
  • Fax: 406-237-4004
Mailing address:
  • Phone: 406-237-4050
  • Fax: 406-237-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number10054
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: