Provider Demographics
NPI:1578664066
Name:FREMONT COUNTY PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:FREMONT COUNTY PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-332-2185
Mailing Address - Street 1:115 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3919
Mailing Address - Country:US
Mailing Address - Phone:307-332-2185
Mailing Address - Fax:307-332-7799
Practice Address - Street 1:115 WYOMING ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3919
Practice Address - Country:US
Practice Address - Phone:307-332-2185
Practice Address - Fax:307-332-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5774A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY111666500Medicaid
WYW308732OtherMEDICARE PTAN