Provider Demographics
NPI:1982775508
Name:WOMENS CLINIC OF NORTHEASTERN WYOMING PC
Entity Type:Organization
Organization Name:WOMENS CLINIC OF NORTHEASTERN WYOMING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PC
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-672-0401
Mailing Address - Street 1:212 W BURKITT ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4206
Mailing Address - Country:US
Mailing Address - Phone:307-672-0401
Mailing Address - Fax:307-672-0317
Practice Address - Street 1:212 W BURKITT ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4206
Practice Address - Country:US
Practice Address - Phone:307-672-0401
Practice Address - Fax:307-672-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2719A207V00000X
WY13730119363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107189100Medicaid
A73191Medicare UPIN
WYW20530Medicare PIN