Provider Demographics
NPI:1932299690
Name:LANDER MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:LANDER MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-332-2941
Mailing Address - Street 1:PO BOX 9432
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9432
Mailing Address - Country:US
Mailing Address - Phone:307-332-2941
Mailing Address - Fax:307-332-1920
Practice Address - Street 1:745 BUENA VISTA
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3431
Practice Address - Country:US
Practice Address - Phone:307-332-2941
Practice Address - Fax:307-332-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207Q00000X
WY0823410001332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00975001OtherBLUE SHIELD OF WYOMING
WY0823410001OtherMEDICARE DMEPOS
WY106224700Medicaid
WYCT0209OtherMEDICARE RAILROAD RETIREM
WY0823410001OtherMEDICARE DMEPOS
WYCT0209OtherMEDICARE RAILROAD RETIREM