MEDICARE: EVANSTON CLINIC CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	363LF0000X	Family Nurse Practitioner
2	207R00000X	Internal Medicine Physician	WY
3	207V00000X	Obstetrics & Gynecology Physician	WY
4	208600000X	Surgery Physician	WY
5	208800000X	Urology Physician	WY
6	208D00000X	General Practice Physician
7	363A00000X	Physician Assistant
8	363AM0700X	Medical Physician Assistant
9	207Q00000X	Family Medicine Physician	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06159001	OTHER	WY	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013916519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANSTON CLINIC CORP

Provider Business Mailing Address
First Line	:	PO BOX 5009
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37024-5009
Country	:	US
Telephone Number	:	615-221-1400
Fax Number	:	615-465-2984

Provider Business Practice Location Address
First Line	:	196 ARROWHEAD DR STE 8
Second Line	:
City	:	EVANSTON
State	:	WY
Zip	:	82930-8752
Country	:	US
Telephone Number	:	307-783-8365
Fax Number	:	307-783-8284

Authorized Official
Title or Position	:	DIRECTOR REVENUE CYCLE
Name	:	LAURA J FEY
Credential	:
Telephone Number	:	615-221-3641

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	03/04/2019

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Directions to “EVANSTON CLINIC CORP ” Practice Location

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