Provider Demographics
NPI:1770503518
Name:INTRAWEST MEDICAL SERVICES, P.C
Entity Type:Organization
Organization Name:INTRAWEST MEDICAL SERVICES, P.C
Other - Org Name:EMERGENCY PHYSICIANS OF LARAMIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CANTWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-745-3169
Mailing Address - Street 1:3908 E GRAND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5173
Mailing Address - Country:US
Mailing Address - Phone:307-745-3168
Mailing Address - Fax:307-742-8449
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5140
Practice Address - Country:US
Practice Address - Phone:307-742-2142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106757500Medicaid
WY4372004Medicare ID - Type UnspecifiedGROUP NUMBER