Provider Demographics
NPI:1164561528
Name:SAGE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SAGE MEDICAL GROUP LLC
Other - Org Name:SAGE MEDICAL GROUP LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-265-8300
Mailing Address - Street 1:PO BOX 50750
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82605
Mailing Address - Country:US
Mailing Address - Phone:307-265-8300
Mailing Address - Fax:307-265-8313
Practice Address - Street 1:419 S WASHINGTON STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-265-8300
Practice Address - Fax:307-265-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory