Provider Demographics
NPI:1588851547
Name:CENTRAL WYOMING SKIN CLINIC PC
Entity Type:Organization
Organization Name:CENTRAL WYOMING SKIN CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENNION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-234-0003
Mailing Address - Street 1:2546 E 2ND ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2062
Mailing Address - Country:US
Mailing Address - Phone:307-234-0003
Mailing Address - Fax:
Practice Address - Street 1:2546 E 2ND ST STE 400
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2062
Practice Address - Country:US
Practice Address - Phone:307-234-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114196100Medicaid
WYW307789Medicare PIN