Basic Information
| Provider Information | |||||||||
| NPI: | 1932219623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRMPOTICH | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1441 WILKINS CIRCLE | ||||||||
| Address2: | GASTROENTEROLOGY ASSOCIATES PC | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072651792 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1441 WILKINS CIRCLE | ||||||||
| Address2: | GASTROENTEROLOGY ASSOCIATES PC | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072651792 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 5835A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0059262 | 05 | MT | MEDICAID | 307220 | 01 | WY | BLUE CROSS | OTHER |