Healthcare Provider Details

I. General information

NPI: 1023553799
Provider Name (Legal Business Name): NORTH CHEYENNE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 SYCAMORE RD 1ST FLOOR
CHEYENNE WY
82009-4347
US

IV. Provider business mailing address

428 S DURBIN ST STE 104
CASPER WY
82601-2818
US

V. Phone/Fax

Practice location:
  • Phone: 307-514-1300
  • Fax:
Mailing address:
  • Phone: 307-337-4284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ZIAD SKAF
Title or Position: CFO
Credential:
Phone: 307-277-9424