Provider Demographics
NPI:1780754317
Name:UROLOGY CARE CLINIC, P.C.
Entity type:Organization
Organization Name:UROLOGY CARE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-632-3111
Mailing Address - Street 1:433 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4643
Mailing Address - Country:US
Mailing Address - Phone:307-632-3111
Mailing Address - Fax:307-778-8649
Practice Address - Street 1:433 E 19TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4643
Practice Address - Country:US
Practice Address - Phone:307-632-3111
Practice Address - Fax:307-778-8649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5500A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9209Medicare ID - Type Unspecified