Provider Demographics
NPI:1619063617
Name:PESSL, ERICH (MD)
Entity Type:Individual
Prefix:MR
First Name:ERICH
Middle Name:
Last Name:PESSL
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 1:120 N 19TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3920
Mailing Address - Country:US
Mailing Address - Phone:406-556-9740
Mailing Address - Fax:406-556-9741
Practice Address - Street 1:120 N 19TH AVE STE A
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3920
Practice Address - Country:US
Practice Address - Phone:406-556-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0013243Medicaid
MT0013243Medicaid
MTF68194Medicare UPIN