Healthcare Provider Details

I. General information

NPI: 1487097762
Provider Name (Legal Business Name): ROBERT TYLER REIDENBAUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TY REIDENBAUGH

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 02/27/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 W MENDENHALL ST STE 202
BOZEMAN MT
59715
US

IV. Provider business mailing address

PO BOX 4369
BOISE ID
83711-4369
US

V. Phone/Fax

Practice location:
  • Phone: 406-219-7233
  • Fax:
Mailing address:
  • Phone: 208-810-2310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMEDPHYSCOMLIC114707
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: