Provider Demographics
NPI:1205005618
Name:YELLOWSTONE SPORTS MEDICINE AND BONE & JOINT CLINIC,LLC
Entity Type:Organization
Organization Name:YELLOWSTONE SPORTS MEDICINE AND BONE & JOINT CLINIC,LLC
Other - Org Name:YELLOWSTONE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:BILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-578-1953
Mailing Address - Street 1:720 LINDSAY LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4103
Mailing Address - Country:US
Mailing Address - Phone:307-578-1992
Mailing Address - Fax:307-578-1990
Practice Address - Street 1:720 LINDSAY LN
Practice Address - Street 2:SUITE B
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4103
Practice Address - Country:US
Practice Address - Phone:307-578-1992
Practice Address - Fax:307-578-1990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3909A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W22409OtherMEDICARE PTAN
WY6198560001Medicare NSC