MEDICARE: SWEETWATER PEDIATRICS P.C.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	6946A	WY

General Provider Information

NPI Number	:	1215135025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SWEETWATER PEDIATRICS P.C.

Provider Business Mailing Address
First Line	:	1204 HILLTOP DR
Second Line	:	SUITE#106
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5861
Country	:	US
Telephone Number	:	307-362-5500
Fax Number	:	307-362-0300

Provider Business Practice Location Address
First Line	:	1204 HILLTOP DR
Second Line	:	SUITE#106
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5861
Country	:	US
Telephone Number	:	307-362-5500
Fax Number	:	307-362-0300

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHANDRASHEKAR YESHLUR
Credential	:	M.D.
Telephone Number	:	307-362-5500

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	08/22/2020

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