1659431013 NPI number — WALLACE S. WILDER MD

Table of content: (NPI 1659431013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659431013 NPI number — WALLACE S. WILDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE S. WILDER MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659431013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 SUNNYVIEW LN
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59901-3135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-752-8300
Provider Business Mailing Address Fax Number:
406-752-3542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 SUNNYVIEW LN
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-3135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-752-8300
Provider Business Practice Location Address Fax Number:
406-752-3542
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAGGENER
Authorized Official First Name:
TRUDY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
406-752-8300

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  3655 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0032344 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 92168 . This is a "BCBS - MICHAEL SCHWALLER" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0437529 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08110 . This is a "BCBS - WALLACE WILDER MD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 371330 . This is a "BCBS - VALERIE BEEBE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0066495 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95755 . This is a "BCBS - LYNN A. DYKSTRA MD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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