Healthcare Provider Details

I. General information

NPI: 1255788592
Provider Name (Legal Business Name): GALLATIN PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N WILLSON AVE SUITE 300C
BOZEMAN MT
59715-3551
US

IV. Provider business mailing address

PO BOX 10095
BOZEMAN MT
59719-0095
US

V. Phone/Fax

Practice location:
  • Phone: 406-577-2346
  • Fax: 866-404-8715
Mailing address:
  • Phone: 406-577-2346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number27907
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number27907
License Number StateMT

VIII. Authorized Official

Name: JARRED MCDANIEL
Title or Position: OWNER
Credential: M.D.
Phone: 406-577-2346