Provider Demographics
NPI:1508900341
Name:MEMORIAL HOSPITAL OF CARBON COUNTY
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF CARBON COUNTY
Other - Org Name:WAGON CIRCLE FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEPLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-324-8347
Mailing Address - Street 1:PO BOX 944
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-0944
Mailing Address - Country:US
Mailing Address - Phone:307-324-9098
Mailing Address - Fax:307-324-6726
Practice Address - Street 1:2012 W ELM STREET
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301
Practice Address - Country:US
Practice Address - Phone:307-324-9098
Practice Address - Fax:307-324-6726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL OF CARBON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-16
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4625A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYDD2243OtherRR MEDICARE
WY120726100Medicaid
WY05726001OtherBCBS OF WYOMING
WY=========OtherWORKERS COMP
WYDD2243OtherRR MEDICARE
WY05726001OtherBCBS OF WYOMING