Provider Demographics
NPI:1881042778
Name:YELLOWSTONE SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:YELLOWSTONE SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-578-1949
Mailing Address - Street 1:720 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4103
Mailing Address - Country:US
Mailing Address - Phone:307-578-1953
Mailing Address - Fax:307-578-1956
Practice Address - Street 1:720 LINDSAY LN
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4103
Practice Address - Country:US
Practice Address - Phone:307-578-1953
Practice Address - Fax:307-578-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3909A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY302474OtherBLUE CROSS BLUE SHIELD
OR297555Medicaid
AKMD323WYMedicaid
MT3505047Medicaid
WY102410800Medicaid
WY302474OtherMEDICARE
MT000082971OtherMEDICARE
WY200009940OtherMEDICARE RAILROAD
WY200009940OtherMEDICARE RAILROAD