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General NPI Number Information
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NPI Number | 1437321650
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Entity Type | Organization
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Legal Business Name | JACKSON HOLE SURGERY
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Dates
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Enumeration Date | 03/27/2008
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Last Update Date | 03/27/2008
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Provider Practice Location Address
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Address Line | 555 E. BROADWAY SUITE 212
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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 | 307-734-1600
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Fax | 307-733-7679
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Provider Business Mailing Address
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Address Line | PO BOX 12976
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City | JACKSON
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State | WY
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Zip | 83002-2976
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Country | US
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Telephone | 307-734-1600
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Fax | 307-733-7679
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Authorized Official
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Title or Position | OWNER
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Name | JAMES M. BALLIRO
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Credential | M.D.
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Telephone | 307-734-1600
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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 | 6475A
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License Number State | WY
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