Healthcare Provider Details

I. General information

NPI: 1669039640
Provider Name (Legal Business Name): BLACK ROCK SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 POWDER BASIN AVE
GILLETTE WY
82718-6406
US

IV. Provider business mailing address

PO BOX 688
DOUGLAS WY
82633-0688
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-6222
  • Fax: 307-682-6999
Mailing address:
  • Phone: 307-358-6200
  • Fax: 307-358-3748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK G MURPHY
Title or Position: OWNER
Credential:
Phone: 307-358-6200