Provider Demographics
NPI:1114998259
Name:NORTHEAST WYOMING PEDIATRIC ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:NORTHEAST WYOMING PEDIATRIC ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-675-5555
Mailing Address - Street 1:916 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2708
Mailing Address - Country:US
Mailing Address - Phone:307-675-5555
Mailing Address - Fax:307-675-5599
Practice Address - Street 1:916 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2708
Practice Address - Country:US
Practice Address - Phone:307-675-5555
Practice Address - Fax:307-675-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000405665Medicaid
SD7705130Medicaid
WY100048900Medicaid
WY00941001OtherBC BS WY
WY00941001OtherBC BS WY