Basic Information
| Provider Information | |||||||||
| NPI: | 1457459125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALM | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 EAST 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077777911 | ||||||||
| FaxNumber: | 3076383616 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 EAST 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076322434 | ||||||||
| FaxNumber: | 3076349295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5752A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110737200 | 05 | WY | MEDICAID | 308136 | 01 | WY | BCBS | OTHER | 080143307 | 01 | WY | RR MEDICARE | OTHER |