Provider Demographics
NPI:1770681439
Name:UNIVERSITY OF WYOMING
Entity Type:Organization
Organization Name:UNIVERSITY OF WYOMING
Other - Org Name:TRI COUNTY MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PLOUCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-632-2434
Mailing Address - Street 1:820 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4714
Mailing Address - Country:US
Mailing Address - Phone:307-632-2434
Mailing Address - Fax:307-638-3616
Practice Address - Street 1:820 E 17TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4714
Practice Address - Country:US
Practice Address - Phone:307-632-2434
Practice Address - Fax:307-638-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107358301Medicaid
WYW4370998Medicare PIN
WY107358301Medicaid