Provider Demographics
NPI:1003865171
Name:BANDOW, GEORGE (MD)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:BANDOW
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:406-329-5606
Practice Address - Street 1:500 W BROADWAY ST STE 320
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8273207RC0000X
MT9853207RI0011X
MTMED-PHYS-LIC-9853207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTA002OtherTRICARE
MTP00062024OtherRAIL ROAD MEDICARE
MT96485OtherBLUE CROSS/BLUE SHIELD
MT67388Medicaid
MT96485OtherBLUE CROSS/BLUE SHIELD
MTP00062024OtherRAIL ROAD MEDICARE