Basic Information
| Provider Information | |||||||||
| NPI: | 1265469506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLATTE COUNTY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 14TH ST | ||||||||
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| City: | WHEATLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 822013201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073223636 | ||||||||
| FaxNumber: | 3073223399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 282NR1301X | N | Hospitals | General Acute Care Hospital | Rural | 341600000X | N | Transportation Services | Ambulance | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 106545906 | 05 | WY | MEDICAID | 106545904 | 05 | WY | MEDICAID |