Basic Information
| Provider Information | |||||||||
| NPI: | 1255372736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 HIGHLAND BLVD | ||||||||
| Address2: | ATTN PFS CREDENTIALING | ||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 875 S COTTONWOOD RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597184208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145336 | ||||||||
| FaxNumber: | 4064145337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 59075 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1255372736 | 05 | MT | MEDICAID |