Provider Demographics
NPI:1215976253
Name:WIND RIVER PEDIATRICS, LLC
Entity type:Organization
Organization Name:WIND RIVER PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-857-5247
Mailing Address - Street 1:1005 COLLEGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2266
Mailing Address - Country:US
Mailing Address - Phone:307-857-5247
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:1005 COLLEGE VIEW DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2266
Practice Address - Country:US
Practice Address - Phone:307-857-5247
Practice Address - Fax:307-857-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7224A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYI38395Medicare UPIN
WY20405Medicare ID - Type Unspecified