Provider Demographics
NPI:1659431013
Name:WALLACE S. WILDER MD
Entity Type:Organization
Organization Name:WALLACE S. WILDER MD
Other - Org Name:SUNNY VIEW PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAGGENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-8300
Mailing Address - Street 1:210 SUNNYVIEW LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3135
Mailing Address - Country:US
Mailing Address - Phone:406-752-8300
Mailing Address - Fax:406-752-3542
Practice Address - Street 1:210 SUNNYVIEW LN
Practice Address - Street 2:SUITE 103
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3135
Practice Address - Country:US
Practice Address - Phone:406-752-8300
Practice Address - Fax:406-752-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3655261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0032344Medicaid
MT92168OtherBCBS - MICHAEL SCHWALLER
MT0437529Medicaid
MT08110OtherBCBS - WALLACE WILDER MD
MT371330OtherBCBS - VALERIE BEEBE
MT0066495Medicaid
MT95755OtherBCBS - LYNN A. DYKSTRA MD
MT08110OtherBCBS - WALLACE WILDER MD