Basic Information
| Provider Information | |||||||||
| NPI: | 1881656940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 925 HIGHLAND BLVD., | ||||||||
| Address2: | SUITE 1180 | ||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065878631 | ||||||||
| FaxNumber: | 4065871343 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 HIGHLAND BLVD., | ||||||||
| Address2: | SUITE 1180 | ||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065878631 | ||||||||
| FaxNumber: | 4065871343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 6907 | MT | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0144690 | 05 | MT | MEDICAID | 0089427 | 05 | MT | MEDICAID |