Provider Demographics
NPI:1720039357
Name:BRECHEEN, ROGER MALCOM (MD FACOG)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MALCOM
Last Name:BRECHEEN
Suffix:
Gender:M
Credentials:MD FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15570
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:307-733-8537
Mailing Address - Fax:307-733-0141
Practice Address - Street 1:555 E BROADWAY
Practice Address - Street 2:STE 201
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-8537
Practice Address - Fax:307-733-0141
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5262A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F61684Medicare UPIN
303548Medicare ID - Type Unspecified