Provider Demographics
NPI:1770536963
Name:THURSTON MEDICAL CLINIC PC
Entity type:Organization
Organization Name:THURSTON MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:THURSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-347-2525
Mailing Address - Street 1:401 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3530
Mailing Address - Country:US
Mailing Address - Phone:307-347-2525
Mailing Address - Fax:307-347-3949
Practice Address - Street 1:401 S 15TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3530
Practice Address - Country:US
Practice Address - Phone:307-347-2525
Practice Address - Fax:307-347-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5442A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117571800Medicaid
1250930001OtherMEDICARE DME
104247300OtherDEPARTMENT OF LABOR
WY308202Medicare ID - Type Unspecified
104247300OtherDEPARTMENT OF LABOR
WY117571800Medicaid