1225331325 NPI number — WYOMING MEDICAL

Table of content: (NPI 1225331325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225331325 NPI number — WYOMING MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING MEDICAL
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:
Provider Other Organization Name Type Code:
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:
1225331325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3060 S BRIDLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83001-9124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-413-2087
Provider Business Mailing Address Fax Number:
877-382-7638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 E BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-413-2087
Provider Business Practice Location Address Fax Number:
877-382-7638
Provider Enumeration Date:
12/10/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUMICAD
Authorized Official First Name:
REDEEM
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
307-413-2087

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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