Basic Information
| Provider Information | |||||||||
| NPI: | 1578664066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT COUNTY PEDIATRIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3073322185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5774A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 111666500 | 05 | WY | MEDICAID | W308732 | 01 | WY | MEDICARE PTAN | OTHER |