Provider Demographics
NPI:1518994961
Name:THOMAS H NIETHAMMER, MD, PC
Entity Type:Organization
Organization Name:THOMAS H NIETHAMMER, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:NIETHAMMER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:307-673-8383
Mailing Address - Street 1:1333 W 5TH ST
Mailing Address - Street 2:STE 206
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-673-8383
Mailing Address - Fax:
Practice Address - Street 1:1333 W 5TH ST
Practice Address - Street 2:STE 206
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-673-8383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3508A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY122049700Medicaid
WY02545001OtherBLUE CROSS
WY02545001OtherBLUE CROSS
WYDE0193Medicare PIN