Provider Demographics
NPI:1437154291
Name:GRACE, ANDREW W (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:W
Last Name:GRACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 HIGHLAND BLVD STE 1200
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6900
Mailing Address - Country:US
Mailing Address - Phone:406-414-5037
Mailing Address - Fax:406-414-5295
Practice Address - Street 1:905 HIGHLAND BLVD
Practice Address - Street 2:STE 4450
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6901
Practice Address - Country:US
Practice Address - Phone:406-585-5037
Practice Address - Fax:406-556-5295
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10338202K00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT45-2860317OtherTAX ID
MT0062917Medicaid
MTH84227Medicare UPIN
MT0062917Medicaid