Basic Information
| Provider Information | |||||||||
| NPI: | 1659458008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHEYENNE REGIONAL PHYSICIANS GROUP, LLC | ||||||||
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| OtherOrganizationName: | CHEYENNE REGIONAL MEDICAL GROUP, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20970 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820037020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074323685 | ||||||||
| FaxNumber: | 3077738013 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077738012 | ||||||||
| FaxNumber: | 3076337676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | GAUTREAU | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3077738012 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 261QS1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.