Provider Demographics
NPI:1932123494
Name:WYOMING MEDICAL GROUP FLLC
Entity Type:Organization
Organization Name:WYOMING MEDICAL GROUP FLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-733-0011
Mailing Address - Street 1:PO BOX 4953
Mailing Address - Street 2:555 E BROADWAY SUITE 216
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001
Mailing Address - Country:US
Mailing Address - Phone:307-733-0011
Mailing Address - Fax:307-733-0089
Practice Address - Street 1:555 EAST BROADWAY
Practice Address - Street 2:SUITE 216
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-0011
Practice Address - Fax:307-733-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G82466Medicare UPIN
10074Medicare ID - Type Unspecified