Provider Demographics
NPI:1295707776
Name:BUKACEK, ANN MARIE (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:BUKACEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 HERITAGE WAY, STE. 102
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3127
Mailing Address - Country:US
Mailing Address - Phone:406-755-7785
Mailing Address - Fax:406-755-7857
Practice Address - Street 1:160 HERITAGE WAY
Practice Address - Street 2:STE. 102
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3161
Practice Address - Country:US
Practice Address - Phone:406-755-7785
Practice Address - Fax:406-755-7857
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO94705OtherBC/BS
MT0063665Medicaid
MT0063665Medicaid