Provider Demographics
NPI:1407892300
Name:GOOSE CREEK PEDIATRICS PC
Entity Type:Organization
Organization Name:GOOSE CREEK PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:I
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-672-7700
Mailing Address - Street 1:1701 W 5TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2748
Mailing Address - Country:US
Mailing Address - Phone:307-672-7700
Mailing Address - Fax:
Practice Address - Street 1:1701 W 5TH ST
Practice Address - Street 2:STE A
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2748
Practice Address - Country:US
Practice Address - Phone:307-672-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY8820875OtherMONTANA MEDICAID
WYC39254Medicare UPIN