Provider Demographics
NPI:1124188545
Name:ANTELOPE MEDICAL CONSULTANTS LLC
Entity Type:Organization
Organization Name:ANTELOPE MEDICAL CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MALODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-682-7661
Mailing Address - Street 1:430 S MEDICAL ARTS CT
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3364
Mailing Address - Country:US
Mailing Address - Phone:307-682-7661
Mailing Address - Fax:307-682-5074
Practice Address - Street 1:430 S MEDICAL ARTS CT
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3364
Practice Address - Country:US
Practice Address - Phone:307-682-7661
Practice Address - Fax:307-682-5074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5806A207R00000X
WY5853A207RC0000X
WY18882.269363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7088727Medicaid
WY00783001OtherBLUE CROSS CLINIC NUMBER
WA7088727Medicaid
WY00783001OtherBLUE CROSS CLINIC NUMBER