Provider Demographics
NPI:1841364882
Name:JACKSON HOLE OBGYN PC
Entity type:Organization
Organization Name:JACKSON HOLE OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:MALCOM
Authorized Official - Last Name:BRECHEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACOG
Authorized Official - Phone:307-733-8537
Mailing Address - Street 1:PO BOX 15570
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:307-733-8537
Mailing Address - Fax:307-733-0141
Practice Address - Street 1:555 E BROADWAY
Practice Address - Street 2:STE 201
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-8537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY307388Medicare ID - Type Unspecified