Basic Information
| Provider Information | |||||||||
| NPI: | 1013916519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANSTON CLINIC CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370245009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152211400 | ||||||||
| FaxNumber: | 6154652984 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 ARROWHEAD DR STE 8 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829308752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077838365 | ||||||||
| FaxNumber: | 3077838284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | FEY | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6152213641 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208600000X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 06159001 | 01 | WY | BCBS | OTHER | 1013916519 | 05 | WY | MEDICAID |