1003952821 NPI number — WYOMING CANCER SPECIALISTS LLC

Table of content: (NPI 1003952821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003952821 NPI number — WYOMING CANCER SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING CANCER SPECIALISTS LLC
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:
1003952821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3576 GARDEN CREEK HTS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82601-6644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-262-5949
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 2ND ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-6260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-382-5116
Provider Business Practice Location Address Fax Number:
307-382-5118
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-382-5116

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X , with the licence number:  6639A , 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: 122649500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05922001 . This is a "BCBS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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