Provider Demographics
NPI:1003894122
Name:JOHNSON COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHNSON COUNTY MEMORIAL HOSPITAL
Other - Org Name:JOHNSON COUNTY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-684-5521
Mailing Address - Street 1:497 WEST LOTT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1609
Mailing Address - Country:US
Mailing Address - Phone:307-684-6188
Mailing Address - Fax:307-684-5385
Practice Address - Street 1:497 WEST LOTT
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1609
Practice Address - Country:US
Practice Address - Phone:307-684-6188
Practice Address - Fax:307-684-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06140208D00000X, 275N00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No275N00000XHospital UnitsMedicare Defined Swing Bed UnitGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00984001OtherBLUE CROSS BLUE SHIELD
WY106561102Medicaid
WY106561110Medicaid
WY007336OtherBLUE CROSS BLUE SHIELD
WY1106561111Medicaid
WY185689800OtherWORKERS COMP & COMMERCIAL
WYY415571OtherWORKERS COMP & COMMERCIAL
WY106561100Medicaid
WY185689800OtherTRICARE
WYY415571OtherTRICARE
WY106561104Medicaid
WY530026OtherWORKERS COMP & COMMERCIAL
WYY415571OtherWORKERS COMP & COMMERCIAL
WY185689800OtherTRICARE
WYW4250300Medicare Oscar/Certification