Basic Information
| Provider Information | |||||||||
| NPI: | 1669674396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST WYOMING PATHOLOGY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177317771 | ||||||||
| FaxNumber: | 8177317774 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177317771 | ||||||||
| FaxNumber: | 8177317774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | WOODWARD | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8177317771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 5471A | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 04744001 | 01 | WY | BCBS | OTHER | 220032568 | 01 | WY | MEDICARE RR | OTHER | 111289900 | 05 | WY | MEDICAID |