Basic Information
| Provider Information | |||||||||
| NPI: | 1033524095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKROVE | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOEHMKE | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7212 COMMONS CIR | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820092667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076354141 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7212 COMMONS CIR | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820092667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076354141 | ||||||||
| FaxNumber: | 3076356587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS13506 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | UO3896 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | 12618A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1033524095 | 05 | WY | MEDICAID |