Healthcare Provider Details

I. General information

NPI: 1801084926
Provider Name (Legal Business Name): EVANSTON CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N MAIN ST
LYMAN WY
82937
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-2829
US

V. Phone/Fax

Practice location:
  • Phone: 307-787-3313
  • Fax:
Mailing address:
  • Phone: 615-465-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateWY

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential: MBA
Phone: 615-465-7626