1508900341 NPI number — MEMORIAL HOSPITAL OF CARBON COUNTY

Table of content: (NPI 1508900341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508900341 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:
WAGON CIRCLE FAMILY MEDICAL 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:
1508900341
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 944
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAWLINS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82301-0944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-324-9098
Provider Business Mailing Address Fax Number:
307-324-6726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2012 W ELM STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAWLINS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-324-9098
Provider Business Practice Location Address Fax Number:
307-324-6726
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: 207Q00000X , with the licence number:  4625A , 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: DD2243 . This is a "RR MEDICARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 120726100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05726001 . This is a "BCBS OF WYOMING" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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