1710928072 NPI number — G GREGG NEIBAUER, DPM, INC

Table of content: (NPI 1710928072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710928072 NPI number — G GREGG NEIBAUER, DPM, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G GREGG NEIBAUER, DPM, INC
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:
1710928072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1845 BANCROFT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59801-5747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-721-4007
Provider Business Mailing Address Fax Number:
406-549-9807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1845 BANCROFT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59801-5747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-721-4007
Provider Business Practice Location Address Fax Number:
406-549-9807
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEIBAUER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
GREGG
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
406-721-4007

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  160 , 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: 0390779 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97315 . This is a "BLUECROSSBLUESHIELD OF MT" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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