Basic Information
| Provider Information | |||||||||
| NPI: | 1417461914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMPBELL COUNTY HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | CAMPBELL COUNTY MEDICAL GROUP-ANESTHESIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076881000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | HUBER | ||||||||
| AuthorizedOfficialFirstName: | DALTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3076881523 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAMPBELL COUNTY HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.