Provider Demographics
NPI:1104883461
Name:THUNDER BASIN ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity type:Organization
Organization Name:THUNDER BASIN ORTHOPAEDICS AND SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-358-6200
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-0688
Mailing Address - Country:US
Mailing Address - Phone:307-358-6200
Mailing Address - Fax:307-358-3748
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-6200
Practice Address - Fax:307-358-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120503000Medicaid
WY10377Medicare ID - Type Unspecified