Healthcare Provider Details

I. General information

NPI: 1295098416
Provider Name (Legal Business Name): TYLER LEE DICKEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 13TH AVE E
POLSON MT
59860-5315
US

IV. Provider business mailing address

PO BOX 262
LIBERTY LAKE WA
99019-0262
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-5680
  • Fax: 406-883-8910
Mailing address:
  • Phone: 406-883-5680
  • Fax: 406-883-8910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number10229A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301101289
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMED-PHYS-LIC-92059
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: