1932299690 NPI number — LANDER MEDICAL CLINIC, PC

Table of content: (NPI 1932299690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932299690 NPI number — LANDER MEDICAL CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANDER MEDICAL CLINIC, PC
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:
1932299690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9432
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-9432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-332-2941
Provider Business Mailing Address Fax Number:
307-332-1920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
745 BUENA VISTA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANDER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82520-3431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-332-2941
Provider Business Practice Location Address Fax Number:
307-332-1920
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEDGES
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
307-332-2941

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 0823410001 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00975001 . This is a "BLUE SHIELD OF WYOMING" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 0823410001 . This is a "MEDICARE DMEPOS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 106224700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CT0209 . This is a "MEDICARE RAILROAD RETIREM" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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