Provider Demographics
NPI:1285621839
Name:MEMORIAL HOSPITAL OF LARAMIE COUNTY
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL OF LARAMIE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-633-6198
Mailing Address - Street 1:214 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3748
Mailing Address - Country:US
Mailing Address - Phone:307-634-2273
Mailing Address - Fax:307-633-3018
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-634-2273
Practice Address - Fax:307-633-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X, 261QM0801X
WY06-201273R00000X, 273Y00000X, 282N00000X
WY06-115314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No273R00000XHospital UnitsPsychiatric Unit
No273Y00000XHospital UnitsRehabilitation Unit
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107334600Medicaid
WY107334602Medicaid
WY107334602Medicaid
WY530014Medicare Oscar/Certification
W9164Medicare UPIN
WY107334600Medicaid
WY535044Medicare Oscar/Certification