Basic Information
| Provider Information | |||||||||
| NPI: | 1285621839 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL OF LARAMIE COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHEYENNE REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
| FaxNumber: | 3076333018 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
| FaxNumber: | 3076333018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3076336198 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 314000000X | 06-115 | WY | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 273R00000X | 06-201 | WY | N | Hospital Units | Psychiatric Unit | 273Y00000X | 06-201 | WY | N | Hospital Units | Rehabilitation Unit | 282N00000X | 06-201 | WY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 107334600 | 05 | WY | MEDICAID | 107334602 | 05 | WY | MEDICAID |