Provider Demographics
NPI:1467544007
Name:HANEBRINK, BRADLEY GREGG (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GREGG
Last Name:HANEBRINK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-0767
Mailing Address - Country:US
Mailing Address - Phone:307-674-5123
Mailing Address - Fax:307-674-5230
Practice Address - Street 1:1401 W 5TH ST
Practice Address - Street 2:SHERIDAN MEMORIAL HOSPITAL
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2705
Practice Address - Country:US
Practice Address - Phone:307-672-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5140A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103008600Medicaid
WY305980OtherBCBS OF WYOMING
WY103008600Medicaid
WY305980OtherBCBS OF WYOMING
F28813Medicare UPIN