Provider Demographics
NPI:1295796050
Name:VEIN TREATMENT CENTER OF CHEYENNE
Entity type:Organization
Organization Name:VEIN TREATMENT CENTER OF CHEYENNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SURBRUGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-635-0226
Mailing Address - Street 1:123 WESTERN HILLS BLVD.
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3446
Mailing Address - Country:US
Mailing Address - Phone:307-638-5149
Mailing Address - Fax:307-635-1924
Practice Address - Street 1:4003 RAWLINS ST. SUITE B
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-637-5600
Practice Address - Fax:307-637-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121833600Medicaid
WYW20440Medicare ID - Type Unspecified