Provider Demographics
NPI:1679582357
Name:MEMORIAL HOSPITAL OF CONVERSE COUNTY
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF CONVERSE COUNTY
Other - Org Name:OREGON TRAIL RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CURT
Authorized Official - Middle Name:
Authorized Official - Last Name:DUGGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-358-2122
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1450
Mailing Address - Country:US
Mailing Address - Phone:307-358-2122
Mailing Address - Fax:307-358-9216
Practice Address - Street 1:525 EAST BIRCH STREET
Practice Address - Street 2:
Practice Address - City:GLENROCK
Practice Address - State:WY
Practice Address - Zip Code:82637
Practice Address - Country:US
Practice Address - Phone:307-436-8838
Practice Address - Fax:307-436-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07163261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY533987Medicare ID - Type Unspecified