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General NPI Number Information
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NPI Number | 1356556518
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Entity Type | Organization
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Legal Business Name | BRENT BLUE MD
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 06/28/2010
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Provider Practice Location Address
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Address Line | 982 W BROADWAY
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City | JACKSON
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State | WY
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Zip | 83001
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Country | US
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Telephone | 307-733-8002
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Fax | 307-733-0032
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Provider Business Mailing Address
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Address Line | PO BOX 15240
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City | JACKSON
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State | WY
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Zip | 83002-5240
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Country | US
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Telephone | 307-733-8002
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Fax | 307-733-0032
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Authorized Official
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Title or Position | OWNER
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Name | BRENT BLUE
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Credential | MD
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Telephone | 307-733-8002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 3416A
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License Number State | WY
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