Basic Information
| Provider Information | |||||||||
| NPI: | 1396751947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYOMING PATHOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270592 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800275009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059478584 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 N 30TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820725140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077422141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARTINCHICK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077422141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 611967200 | 01 | WY | DOL BLACK LUNG | OTHER | 86079 | 01 | WY | ALTIUS HEALTHCARE | OTHER | 106246800 | 05 | WY | MEDICAID |