Provider Demographics
NPI:1871629832
Name:FAMILY CLINIC
Entity Type:Organization
Organization Name:FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:IDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-235-8552
Mailing Address - Street 1:1315 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2212
Mailing Address - Country:US
Mailing Address - Phone:307-235-8552
Mailing Address - Fax:307-235-4656
Practice Address - Street 1:1315 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2212
Practice Address - Country:US
Practice Address - Phone:307-235-8552
Practice Address - Fax:307-235-4656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY102746800Medicaid
WY307211Medicare ID - Type UnspecifiedPROVIDER ID