Provider Demographics
NPI:1255372736
Name:WALSH, PETER (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WALSH
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HIGHLAND BLVD
Mailing Address - Street 2:ATTN PFS CREDENTIALING
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-5000
Mailing Address - Fax:
Practice Address - Street 1:875 S COTTONWOOD RD STE 200
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4208
Practice Address - Country:US
Practice Address - Phone:406-414-5336
Practice Address - Fax:406-414-5337
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT59075207RG0100X
MI5101009213207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1255372736Medicaid
COP00001798OtherRRPTAN
CO01303684Medicaid
COC484288Medicare PIN