Provider Demographics
NPI:1477627982
Name:BIRD, JACE A (DO)
Entity Type:Individual
Prefix:DR
First Name:JACE
Middle Name:A
Last Name:BIRD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 15TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442-7751
Mailing Address - Country:US
Mailing Address - Phone:406-622-5485
Mailing Address - Fax:406-622-5670
Practice Address - Street 1:1203 15TH ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442-7751
Practice Address - Country:US
Practice Address - Phone:406-622-5485
Practice Address - Fax:406-622-5670
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12468207Q00000X
WI45865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010163203OtherREGENCE BLUE SHIELD
IDS6168OtherBLUE CROSS
ID325215OtherALTIUS
ID807833000Medicaid
ID325215OtherALTIUS
IDS6168OtherBLUE CROSS