Basic Information
| Provider Information | |||||||||
| NPI: | 1467544007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANEBRINK | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | GREGG | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 767 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828010767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076745123 | ||||||||
| FaxNumber: | 3076745230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 W 5TH ST | ||||||||
| Address2: | SHERIDAN MEMORIAL HOSPITAL | ||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076721000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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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 | 207L00000X | 5140A | WY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 103008600 | 05 | WY | MEDICAID | 305980 | 01 | WY | BCBS OF WYOMING | OTHER |