Basic Information
| Provider Information | |||||||||
| NPI: | 1265743348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | TERESE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 CENTENNIAL AVE | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067234075 | ||||||||
| FaxNumber: | 4064966035 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S CLARK ST | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067232500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD162973 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-1119 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34591 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500657667 | 05 | OR | MEDICAID |