Basic Information
| Provider Information | |||||||||
| NPI: | 1801084926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANSTON CLINIC CORP | ||||||||
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| OtherOrganizationName: | BRIDGER VALLEY FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 COMMERCE WAY | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 107 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LYMAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077873313 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVANSTON CLINIC CORP | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.