1194869115 NPI number — MEMORIAL HOSPITAL OF CARBON COUNTY

Table of content: (NPI 1194869115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194869115 NPI number — MEMORIAL HOSPITAL OF CARBON COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL HOSPITAL OF CARBON COUNTY
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:
ENERGY BASIN CLINIC
Provider Other Organization Name Type Code:
3
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:
1194869115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 689
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANNA
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82327-0689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-325-6596
Provider Business Mailing Address Fax Number:
307-325-6597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 FELDSPAR COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANNA
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-325-6596
Provider Business Practice Location Address Fax Number:
307-325-6597
Provider Enumeration Date:
02/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KEPLINGER
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
307-324-8347

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  2916A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 107205600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1399310 . This is a "UMWA" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 00863001 . This is a "BCBS OF WYOMING" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 185872500 . This is a "FEDERAL WORKERS COMP" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".