MEDICARE: WALLACE DALE PROPHET MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	9734	AL
2	207RP1001X	Pulmonary Disease Physician	49643	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942294426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALLACE DALE PROPHET MD

Provider Business Mailing Address
First Line	:	350 HERITAGE WAY
Second Line	:	SUITE 2100
City	:	KALISPELL
State	:	MT
Zip	:	59901-3158
Country	:	US
Telephone Number	:	406-257-8992
Fax Number	:	406-755-4161

Provider Business Practice Location Address
First Line	:	350 HERITAGE WAY
Second Line	:	SUITE 2100
City	:	KALISPELL
State	:	MT
Zip	:	59901-3158
Country	:	US
Telephone Number	:	406-257-8992
Fax Number	:	406-755-4161

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	08/22/2017

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Directions to “ WALLACE DALE PROPHET MD” Practice Location

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