Provider Demographics
NPI:1255385787
Name:RODEWALD, GARY D (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:RODEWALD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2345
Mailing Address - Country:US
Mailing Address - Phone:406-363-2211
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1200 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2345
Practice Address - Country:US
Practice Address - Phone:406-363-2211
Practice Address - Fax:406-375-4590
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN22190367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009917OtherMEDICARE GROUP
ID1255385787Medicaid
MT1255385787Medicaid
MT1255385787Medicaid