Provider Demographics
NPI:1477874600
Name:SCHALLOCK, ERIC M (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:SCHALLOCK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 RIDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-8977
Mailing Address - Country:US
Mailing Address - Phone:406-883-3737
Mailing Address - Fax:406-883-2669
Practice Address - Street 1:107 RIDGEWATER DR
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-8977
Practice Address - Country:US
Practice Address - Phone:406-676-4441
Practice Address - Fax:406-676-0835
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT903393OtherBCBS