1336289552 NPI number — IVINSON MEMORIAL HOSPITAL

Table of content: (NPI 1336289552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336289552 NPI number — IVINSON MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVINSON MEMORIAL HOSPITAL
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:
1336289552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 N 30TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82072-5140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-742-2142
Provider Business Mailing Address Fax Number:
307-742-0678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 N 30TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82072-5140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-742-2142
Provider Business Practice Location Address Fax Number:
307-742-0678
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BANDS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
307-755-4603

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  07108 , 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: 00710001 . This is a "BCBS PROFESSIONAL" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 107332001 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107332008 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 836000188 . This is a "CHAMPUS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 836000188 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 007153 . This is a "BCBS - INSTITUTIONAL" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 107332002 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 836000188 . This is a "GREAT WEST - WYOMING" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: W4251905 . This is a "PTAN FOR PART B" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 107332000 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107332003 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95682704 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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