Provider Demographics
NPI:1154500544
Name:NEIBAUER, G GREGG (DPM)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:GREGG
Last Name:NEIBAUER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5747
Mailing Address - Country:US
Mailing Address - Phone:406-721-4007
Mailing Address - Fax:406-549-9807
Practice Address - Street 1:1845 BANCROFT ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5747
Practice Address - Country:US
Practice Address - Phone:406-721-4007
Practice Address - Fax:406-549-9807
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT160213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP00097318OtherRAILROAD MEDICARE
MT97315OtherBLUE CROSS BLUE SHIELD
MT000084041OtherMEDICARE GROUP PIN
MT0390779Medicaid
MT97315OtherBLUE CROSS BLUE SHIELD
MTU81726Medicare UPIN
MT0390779Medicaid