Provider Demographics
NPI:1487097762
Name:REIDENBAUGH, ROBERT TYLER (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:TYLER
Last Name:REIDENBAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TY
Other - Middle Name:
Other - Last Name:REIDENBAUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4369
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4369
Mailing Address - Country:US
Mailing Address - Phone:208-810-2310
Mailing Address - Fax:
Practice Address - Street 1:5 W MENDENHALL ST
Practice Address - Street 2:STE 202
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-219-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMEDPHYSCOMLIC1147072084A0401X
WAMD607040172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine