Basic Information
| Provider Information | |||||||||
| NPI: | 1548771421 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CEDARS HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CEDARS WOMEN'S HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 428 S DURBIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073374284 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 428 S DURBIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073374284 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2017 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | SKAF | ||||||||
| AuthorizedOfficialFirstName: | MICHEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3073374284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CEDARS HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.