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General NPI Number Information
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NPI Number | 1356406557
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Entity Type | Organization
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Legal Business Name | ST JOHN'S SURGICAL GROUP, PC
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Dates
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Enumeration Date | 12/27/2006
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Last Update Date | 09/25/2014
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Provider Practice Location Address
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Address Line | 555 E BROADWAY AVE SUITE 229
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City | JACKSON
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State | WY
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Zip | 83001-8640
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Country | US
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Telephone | 307-733-0422
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Fax | 307-733-2580
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Provider Business Mailing Address
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Address Line | PO BOX 4197
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City | JACKSON
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State | WY
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Zip | 83001-4197
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Country | US
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Telephone | 307-733-0422
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Fax | 307-733-2580
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL ROSENBERG
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Credential | MD
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Telephone | 307-733-0422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 5051A
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License Number State | WY
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