Provider Demographics
NPI:1508832080
Name:UROLOGICAL SERVICES OF NORTHERN WYOMING PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:UROLOGICAL SERVICES OF NORTHERN WYOMING PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-587-5131
Mailing Address - Street 1:225 W YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8702
Mailing Address - Country:US
Mailing Address - Phone:307-587-5131
Mailing Address - Fax:307-587-5132
Practice Address - Street 1:225 W YELLOWSTONE AVE
Practice Address - Street 2:SUITE #9
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-8702
Practice Address - Country:US
Practice Address - Phone:307-587-5131
Practice Address - Fax:307-587-5132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7308A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF1105OtherRAILROAD MEDICARE
WY122121300Medicaid
611975900OtherFEDERAL WORK COMP
WY314014OtherBLUE CROSS BLUE SHIELD
WYW20759Medicare PIN