Healthcare Provider Details

I. General information

NPI: 1356325278
Provider Name (Legal Business Name): CHEYENNE MEDICAL SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 POWDERHOUSE RD
CHEYENNE WY
82009
US

IV. Provider business mailing address

5050 POWDERHOUSE RD
CHEYENNE WY
82009
US

V. Phone/Fax

Practice location:
  • Phone: 307-772-8226
  • Fax: 307-634-1271
Mailing address:
  • Phone: 307-772-8226
  • Fax: 307-634-1271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT MATTHEW MONGER
Title or Position: PARTNER OWNER
Credential: MD
Phone: 307-772-8226