Basic Information
| Provider Information | |||||||||
| NPI: | 1851439681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREGORY P CLIFFORD MD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LANDER VALLEY EMERGENCY PHYSICIANS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1276 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846531276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014233306 | ||||||||
| FaxNumber: | 8014233309 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 BISHOP RANDALL DR | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014233306 | ||||||||
| FaxNumber: | 8014233309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLIFFORD | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3074382043 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Personal Emergency Response Attendant |
ID Information
| ID | Type | State | Issuer | Description | 119261200 | 05 | WY | MEDICAID |