Healthcare Provider Details

I. General information

NPI: 1902984776
Provider Name (Legal Business Name): DOUGLAS A. HADLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 ELLIS ST STE 201
BOZEMAN MT
59715-8811
US

IV. Provider business mailing address

1648 ELLIS ST STE 201
BOZEMAN MT
59715-8811
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 TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA78906
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMED-PHYS-LIC-43501
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: