MEDICARE: APPLEGATE FAMILY PRACTICE CLINIC LLC

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	207Q00000X	Family Medicine Physician	7207A	WY

General Provider Information

NPI Number	:	1962544742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APPLEGATE FAMILY PRACTICE CLINIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 343
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82902-0343
Country	:	US
Telephone Number	:	307-371-7192
Fax Number	:	307-382-7750

Provider Business Practice Location Address
First Line	:	1204 HILLTOP DR
Second Line	:	111
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5861
Country	:	US
Telephone Number	:	307-371-7192
Fax Number	:	307-382-7750

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS E APPLEGATE
Credential	:	M.D.
Telephone Number	:	307-371-7192

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/22/2020

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