=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194554998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDPORTAL NETWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2024
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5830 E 2ND ST STE 7000
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-282-4020
-----------------------------------------------------
Fax | 929-282-4020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5830 E 2ND ST STE 7000
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-282-4020
-----------------------------------------------------
Fax | 929-282-4020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZING REPRESENTATIVE
-----------------------------------------------------
Name | MATTHEW SESSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 929-282-4020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------