Provider Demographics
NPI:1861439408
Name:SMITH, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:SMITH
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 1:1224 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2338
Mailing Address - Country:US
Mailing Address - Phone:406-375-4823
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1224 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2338
Practice Address - Country:US
Practice Address - Phone:406-363-1100
Practice Address - Fax:406-363-2148
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT010001507OtherMEDICARE BITTERROOT CLINIC
MT000070892OtherMEDICARE MDMH
MT1861439408Medicaid
MT1861439408Medicaid