=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295878783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | P GEORGE POORE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 EAST BROADWAY STE 212
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-4777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-739-4662
-----------------------------------------------------
Fax | 307-733-7679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4777
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-4777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-739-4662
-----------------------------------------------------
Fax | 307-733-7679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 5778A
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------