1922112374 NPI number — UNIVERSITY OF WYOMING STUDENT HEALTH SERVICE

Table of content: (NPI 1922112374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922112374 NPI number — UNIVERSITY OF WYOMING STUDENT HEALTH SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF WYOMING STUDENT HEALTH SERVICE
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:
UW STUDENT HEALTH SERVICE
Provider Other Organization Name Type Code:
5
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:
1922112374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E. UNIVERSITY AVE
Provider Second Line Business Mailing Address:
DEPT. 3068
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-766-2130
Provider Business Mailing Address Fax Number:
307-766-2711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E. UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
DEPT. 3068
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-766-2130
Provider Business Practice Location Address Fax Number:
307-766-2711
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENDER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
M.D./DIRECTOR
Authorized Official Telephone Number:
307-766-2130

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X , 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: 107362102 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107362103 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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