Provider Demographics
NPI:1568632586
Name:P GEORGE POORE MD PC
Entity Type:Organization
Organization Name:P GEORGE POORE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:P
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:POORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-739-4662
Mailing Address - Street 1:PO BOX 4777
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4777
Mailing Address - Country:US
Mailing Address - Phone:307-739-4662
Mailing Address - Fax:307-733-7679
Practice Address - Street 1:555 E BROADWAY
Practice Address - Street 2:STE 212
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-4777
Practice Address - Country:US
Practice Address - Phone:307-739-4662
Practice Address - Fax:307-733-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5778A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY11570700Medicaid
WYW9442Medicare PIN
WY11570700Medicaid