Healthcare Provider Details

I. General information

NPI: 1902786676
Provider Name (Legal Business Name): MEMORIAL HOSPITAL OF LARAMIE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E 23RD ST
CHEYENNE WY
82001-3748
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-432-6629
  • Fax: 307-996-4525
Mailing address:
  • Phone: 307-432-6629
  • Fax: 307-996-4525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRAD WHITE
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 307-633-6198