Provider Demographics
NPI:1003952821
Name:WYOMING CANCER SPECIALISTS LLC
Entity Type:Organization
Organization Name:WYOMING CANCER SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-382-5116
Mailing Address - Street 1:3576 GARDEN CREEK HTS
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6644
Mailing Address - Country:US
Mailing Address - Phone:307-262-5949
Mailing Address - Fax:
Practice Address - Street 1:400 2ND ST
Practice Address - Street 2:SUITE D
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6260
Practice Address - Country:US
Practice Address - Phone:307-382-5116
Practice Address - Fax:307-382-5118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6639A207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY122649500Medicaid
WY05922001OtherBCBS
WY05922001OtherBCBS
WY20496Medicare ID - Type UnspecifiedGROUP NUMBER