Individual
DR. SAM A WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
341 W PINE ST, MISSOULA, MT 59802-4119
(406) 327-0269
(406) 327-0264
Mailing address
341 W PINE ST, MISSOULA, MT 59802-4119
(406) 327-0269
(406) 327-0264
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
8667
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
091831
BCBS MT
MT
Enumeration date
03/13/2007
Last updated
07/08/2007
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