Provider Demographics
NPI:1649388497
Name:SUPAK, ALLAN R (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:R
Last Name:SUPAK
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 1:320 ALPENGLOW LANE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047
Mailing Address - Country:US
Mailing Address - Phone:406-823-6414
Mailing Address - Fax:406-823-6287
Practice Address - Street 1:320 ALPENGLOW LANE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047
Practice Address - Country:US
Practice Address - Phone:406-823-6414
Practice Address - Fax:406-823-6287
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8521207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0014110Medicaid
MT000018171OtherBLUECROSSBLUESHIELD
MT000070988Medicare PIN
MT000082875Medicare PIN
MTC95537Medicare UPIN
MT000018171OtherBLUECROSSBLUESHIELD
MT080137103Medicare PIN