Healthcare Provider Details

I. General information

NPI: 1528261161
Provider Name (Legal Business Name): SAGEBRUSH E.N.T., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 W 4TH ST
GILLETTE WY
82716-3327
US

IV. Provider business mailing address

1405 W 4TH ST
GILLETTE WY
82716-3327
US

V. Phone/Fax

Practice location:
  • Phone: 307-685-1442
  • Fax:
Mailing address:
  • Phone: 307-685-1442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number5649A
License Number StateWY

VIII. Authorized Official

Name: DR. SIGSBEE WALTER DUCK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 307-685-1442