Provider Demographics
NPI:1043379472
Name:BIG HORN UROLOGY PC
Entity Type:Organization
Organization Name:BIG HORN UROLOGY PC
Other - Org Name:DR STEPHEN W HOLST MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT BIG HORN UROLOGY PC
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:HOLST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-672-1806
Mailing Address - Street 1:340 WEST DOW STREET
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-672-1806
Mailing Address - Fax:307-672-1808
Practice Address - Street 1:340 WEST DOW STREET
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-672-1806
Practice Address - Fax:307-672-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5434A208800000X
CO2157208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109407600Medicaid
WY306592OtherBLUE CROSS BLUE SHIELD
WY306592OtherBLUE CROSS BLUE SHIELD
WY109407600Medicaid