Provider Demographics
NPI:1437321650
Name:JACKSON HOLE SURGERY
Entity Type:Organization
Organization Name:JACKSON HOLE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:BALLIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-734-1600
Mailing Address - Street 1:PO BOX 12976
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-2976
Mailing Address - Country:US
Mailing Address - Phone:307-734-1600
Mailing Address - Fax:307-733-7679
Practice Address - Street 1:555 E. BROADWAY
Practice Address - Street 2:SUITE 212
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-734-1600
Practice Address - Fax:307-733-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6475A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty