Provider Demographics
NPI:1881656940
Name:WALLACE, RICHARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:WALLACE
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 1:925 HIGHLAND BLVD.,
Mailing Address - Street 2:SUITE 1180
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-587-8631
Mailing Address - Fax:406-587-1343
Practice Address - Street 1:925 HIGHLAND BLVD.,
Practice Address - Street 2:SUITE 1180
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-587-8631
Practice Address - Fax:406-587-1343
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6907174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0144690Medicaid
MT0089427Medicaid
MT0089427Medicaid