Healthcare Provider Details

I. General information

NPI: 1184686859
Provider Name (Legal Business Name): BRUCE SPEICHER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 13TH AVE E
POLSON MT
59860
US

IV. Provider business mailing address

6 13TH AVE E
POLSON MT
59860-5315
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 Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number02000995
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number68487
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100318640A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 2
Identifier000000181694
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM
# 3
Identifier114340109
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 4
Identifier930101007
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerRAIL ROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: