Basic Information
| Provider Information | |||||||||
| NPI: | 1477542231 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL ASSOCIATES OF NORTHERN WYOMING, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 449 MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077544559 | ||||||||
| FaxNumber: | 3077547733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 9TH ST | ||||||||
| Address2: | |||||||||
| City: | CODY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824143433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075871257 | ||||||||
| FaxNumber: | 3075877394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3075871257 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00004001 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | CJ4682 | 01 | WY | RAILROAD MEDICARE | OTHER |