Provider Demographics
NPI:1033221569
Name:SOUTH LINCOLN HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SOUTH LINCOLN HOSPITAL DISTRICT
Other - Org Name:SOUTH LINCOLN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-877-4401
Mailing Address - Street 1:711 ONYX ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3214
Mailing Address - Country:US
Mailing Address - Phone:307-877-4401
Mailing Address - Fax:307-877-3236
Practice Address - Street 1:711 ONYX ST
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3214
Practice Address - Country:US
Practice Address - Phone:307-877-4401
Practice Address - Fax:307-877-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 208600000X, 208M00000X
WY06-148282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105993902Medicaid
WY105993900Medicaid
WY00918001OtherBLUE SHIELD
WY320145OtherBLACK LUNG
WY105993909Medicaid
185636600OtherFEDERAL WORKER'S COMP
WY105993904Medicaid
WY007401OtherBLUE CROSS
5442OtherUNION PACIFIC RAILROAD
WY105993902Medicaid
=========831010000OtherTRICARE
WYW4251602Medicare ID - Type UnspecifiedHOSPITAL MEDICARE PART B
WY105993900Medicaid