Provider Demographics
NPI:1194849331
Name:LANDER VALLEY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:LANDER VALLEY MEDICAL CENTER LLC
Other - Org Name:LANDER VALLEY MEDICAL CENTER HOSPITALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIVISION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1590
Mailing Address - Street 1:1320 BISHOP RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3939
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1320 BISHOP RANDALL DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3939
Practice Address - Country:US
Practice Address - Phone:307-335-6509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE POINT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-16
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115864300Medicaid
WYW308671Medicare PIN