Provider Demographics
NPI:1437416443
Name:FRONTIER MEDICAL PROVIDERS
Entity Type:Organization
Organization Name:FRONTIER MEDICAL PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SURDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-773-8133
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-0426
Mailing Address - Country:US
Mailing Address - Phone:307-426-4676
Mailing Address - Fax:
Practice Address - Street 1:433 E 19TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4643
Practice Address - Country:US
Practice Address - Phone:307-773-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-15
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7206A261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care