Basic Information
| Provider Information | |||||||||
| NPI: | 1124041140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY ASSOCIATES OF WYOMING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1241 W MINERAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037590854 | ||||||||
| FaxNumber: | 3037590864 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
| FaxNumber: | 3036337671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3037590854 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 120962100 | 05 | WY | MEDICAID |