Basic Information
Provider Information
NPI: 1336289552
EntityType: 2
ReplacementNPI:  
OrganizationName: IVINSON MEMORIAL HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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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:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282NR1301X07108WYY HospitalsGeneral Acute Care HospitalRural

ID Information
IDTypeStateIssuerDescription
0071000101WYBCBS PROFESSIONALOTHER
10733200105WY MEDICAID
10733200805WY MEDICAID
83600018801WYCHAMPUSOTHER
83600018801WYUNITED HEALTHCAREOTHER
00715301WYBCBS - INSTITUTIONALOTHER
10733200205WY MEDICAID
83600018801WYGREAT WEST - WYOMINGOTHER
W425190501WYPTAN FOR PART BOTHER
10733200005WY MEDICAID
10733200305WY MEDICAID
9568270405CO MEDICAID


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