Provider Demographics
NPI:1952585861
Name:IVINSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:IVINSON MEMORIAL HOSPITAL
Other - Org Name:IVINSON MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-755-4603
Mailing Address - Street 1:255 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5195
Mailing Address - Country:US
Mailing Address - Phone:307-742-2141
Mailing Address - Fax:307-742-0678
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5195
Practice Address - Country:US
Practice Address - Phone:307-742-2141
Practice Address - Fax:307-766-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
WY08/186282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY532306Medicare Oscar/Certification