Basic Information
| Provider Information | |||||||||
| NPI: | 1356496491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL HOSPITAL OF CONVERSE COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1450 | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826331450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073589216 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073589216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DUGGER | ||||||||
| AuthorizedOfficialFirstName: | CURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3073582122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 00946001 | 01 | WY | BLUE CROSS WY PHYS GROUP | OTHER |