Healthcare Provider Details

I. General information

NPI: 1053539536
Provider Name (Legal Business Name): ORTHOPAEDIC ASSOCIATES IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 W BROADWAY SUITE 202
JACKSON WY
83001-7369
US

IV. Provider business mailing address

PO BOX 7369
JACKSON WY
83002-7369
US

V. Phone/Fax

Practice location:
  • Phone: 307-734-5999
  • Fax:
Mailing address:
  • Phone: 307-734-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARY C NEAL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 307-734-5999