Basic Information
| Provider Information | |||||||||
| NPI: | 1902984776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADLEY | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1648 ELLIS ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597158811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065878631 | ||||||||
| FaxNumber: | 4065871343 | ||||||||
| Practice Location | |||||||||
| Address1: | 1648 ELLIS ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597158811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065878631 | ||||||||
| FaxNumber: | 4065871343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | A78906 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | MED-PHYS-LIC-43501 | MT | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A789060 | 05 | CA | MEDICAID |