Provider Demographics
NPI:1649239138
Name:LAWRENCE W OHOLLERAN PC
Entity Type:Organization
Organization Name:LAWRENCE W OHOLLERAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:OHOLLERAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-637-5600
Mailing Address - Street 1:1616 E 19TH ST
Mailing Address - Street 2:STE 8
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4946
Mailing Address - Country:US
Mailing Address - Phone:307-637-5600
Mailing Address - Fax:307-637-0249
Practice Address - Street 1:1616 E 19TH ST
Practice Address - Street 2:STE 8
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4946
Practice Address - Country:US
Practice Address - Phone:307-637-5600
Practice Address - Fax:307-637-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6423A208600000X
NE16963208600000X
CO26688208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA106329/COA106330OtherMEDICARE/TRAILBLAZER HEALTH ENTERPRISES
WY115489300Medicaid
COA106329/COA106330OtherMEDICARE/TRAILBLAZER HEALTH ENTERPRISES
308529Medicare ID - Type Unspecified