Basic Information
Provider Information | |||||||||
NPI: | 1386303915 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHEYENNE REGIONAL PHYSICIANS GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 20970 | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820037020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3079964777 | ||||||||
FaxNumber: | 3077738013 | ||||||||
Practice Location | |||||||||
Address1: | 800 E 20TH ST STE 230 | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820013869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3079964770 | ||||||||
FaxNumber: | 3076388851 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2021 | ||||||||
LastUpdateDate: | 12/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEN | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING SERVICES | ||||||||
AuthorizedOfficialTelephone: | 3077738237 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHEYENNE REGIONAL PHYSICIANS GROUP, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RE0101X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.