Healthcare Provider Details

I. General information

NPI: 1356556518
Provider Name (Legal Business Name): BRENT BLUE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 W BROADWAY
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 15240
JACKSON WY
83002-5240
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-8002
  • Fax: 307-733-0032
Mailing address:
  • Phone: 307-733-8002
  • Fax: 307-733-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number3416A
License Number StateWY

VIII. Authorized Official

Name: BRENT BLUE
Title or Position: OWNER
Credential: MD
Phone: 307-733-8002