Healthcare Provider Details

I. General information

NPI: 1881656940
Provider Name (Legal Business Name): RICHARD M. WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 HIGHLAND BLVD., SUITE 1180
BOZEMAN MT
59715
US

IV. Provider business mailing address

925 HIGHLAND BLVD., SUITE 1180
BOZEMAN MT
59715
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-8631
  • Fax: 406-587-1343
Mailing address:
  • Phone: 406-587-8631
  • Fax: 406-587-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6907
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: