Provider Demographics
NPI:1477542231
Name:SURGICAL ASSOCIATES OF NORTHERN WYOMING, P.C.
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF NORTHERN WYOMING, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:307-587-1257
Mailing Address - Street 1:449 MOUNTAIN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2232
Mailing Address - Country:US
Mailing Address - Phone:307-754-4559
Mailing Address - Fax:307-754-7733
Practice Address - Street 1:1021 9TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3433
Practice Address - Country:US
Practice Address - Phone:307-587-1257
Practice Address - Fax:307-587-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00004001OtherBLUE CROSS BLUE SHIELD
WYCJ4682OtherRAILROAD MEDICARE
WY00004001OtherBLUE CROSS BLUE SHIELD