Basic Information
Provider Information | |||||||||
NPI: | 1336289552 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IVINSON MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 N 30TH ST | ||||||||
Address2: |   | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 820725140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077422142 | ||||||||
FaxNumber: | 3077420678 | ||||||||
Practice Location | |||||||||
Address1: | 255 N 30TH ST | ||||||||
Address2: |   | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 820725140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077422142 | ||||||||
FaxNumber: | 3077420678 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 12/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BANDS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3077554603 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 07108 | WY | Y |   | Hospitals | General Acute Care Hospital | Rural |
ID Information
ID | Type | State | Issuer | Description | 00710001 | 01 | WY | BCBS PROFESSIONAL | OTHER | 107332001 | 05 | WY |   | MEDICAID | 107332008 | 05 | WY |   | MEDICAID | 836000188 | 01 | WY | CHAMPUS | OTHER | 836000188 | 01 | WY | UNITED HEALTHCARE | OTHER | 007153 | 01 | WY | BCBS - INSTITUTIONAL | OTHER | 107332002 | 05 | WY |   | MEDICAID | 836000188 | 01 | WY | GREAT WEST - WYOMING | OTHER | W4251905 | 01 | WY | PTAN FOR PART B | OTHER | 107332000 | 05 | WY |   | MEDICAID | 107332003 | 05 | WY |   | MEDICAID | 95682704 | 05 | CO |   | MEDICAID |