Healthcare Provider Details

I. General information

NPI: 1972701381
Provider Name (Legal Business Name): WYOMING ORTHOPEDIC AND SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 POWDERHOUSE RD
CHEYENNE WY
82009-4800
US

IV. Provider business mailing address

PO BOX 21330
CHEYENNE WY
82003-7026
US

V. Phone/Fax

Practice location:
  • Phone: 307-633-7943
  • Fax: 307-432-2676
Mailing address:
  • Phone: 307-633-7943
  • Fax: 307-432-2676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWY

VIII. Authorized Official

Name: BRUCE D SMITH
Title or Position: OWNER
Credential: M.D.
Phone: 307-633-7943