Provider Demographics
NPI:1811901515
Name:SOUTH BIG HORN COUNTY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:SOUTH BIG HORN COUNTY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-568-1426
Mailing Address - Street 1:388 SOUTH US HWY 20
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-8902
Mailing Address - Country:US
Mailing Address - Phone:307-568-3311
Mailing Address - Fax:307-568-2139
Practice Address - Street 1:388 SOUTH US HWY 20
Practice Address - Street 2:
Practice Address - City:BASIN
Practice Address - State:WY
Practice Address - Zip Code:82410-8902
Practice Address - Country:US
Practice Address - Phone:307-568-3311
Practice Address - Fax:307-568-2139
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH BIG HORN COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X, 261QR1300X
WY06-139261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110012203Medicaid
WY110012205Medicaid
WY115069300Medicaid
WYBLUE CROSSOther722001
WY110012205Medicaid
WYW306300Medicare ID - Type UnspecifiedPART B GROUP
WY110012203Medicaid
WY=========82410B0001OtherTRICARE
WYG35813Medicare UPIN