=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760734602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. VINCENT HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2012
-----------------------------------------------------
Last Update Date | 03/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 9TH ST STE B
-----------------------------------------------------
City | CODY
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82414-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-587-5622
-----------------------------------------------------
Fax | 307-587-5657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 9TH ST STE B
-----------------------------------------------------
City | CODY
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82414-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-587-5622
-----------------------------------------------------
Fax | 307-587-5657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | STEVE LOVELESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-237-3070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 13258
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------