Healthcare Provider Details

I. General information

NPI: 1992230239
Provider Name (Legal Business Name): COREY GAUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
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: 667-472-4558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58568
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR76048
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMED-PHYS-LIC-83216
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: