1770503518 NPI number — INTRAWEST MEDICAL SERVICES, P.C

Table of content: (NPI 1770503518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770503518 NPI number — INTRAWEST MEDICAL SERVICES, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTRAWEST MEDICAL SERVICES, P.C
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:
6
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:
1770503518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3908 E GRAND AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82070-5173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-745-3168
Provider Business Mailing Address Fax Number:
307-742-8449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 N 30TH ST
Provider Second Line Business Practice Location Address:
EMERGENCY DEPARTMENT
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:
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANTWAY
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
307-745-3169

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106757500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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