Provider Demographics
NPI:1164599379
Name:WYOMING SURGICAL CENTER MRI
Entity Type:Organization
Organization Name:WYOMING SURGICAL CENTER MRI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-472-8781
Mailing Address - Street 1:4140 CENTENNIAL HILLS BLVD #C
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:307-472-8781
Mailing Address - Fax:307-472-8887
Practice Address - Street 1:4140 CENTENNIAL HILLS BLVD
Practice Address - Street 2:#C
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3265
Practice Address - Country:US
Practice Address - Phone:307-472-8781
Practice Address - Fax:307-472-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY35-2-9042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYWY00549OtherBLUE CROSS BLUE SHIELD OF WYOMING
WYP00092902OtherRAILROAD MEDICARE
WYP00092902OtherRAILROAD MEDICARE
WY=========001OtherTRIWEST