Provider Demographics
NPI:1336289552
Name:IVINSON MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:IVINSON MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-755-4603
Mailing Address - Street 1:255 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5140
Mailing Address - Country:US
Mailing Address - Phone:307-742-2142
Mailing Address - Fax:307-742-0678
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5140
Practice Address - Country:US
Practice Address - Phone:307-742-2142
Practice Address - Fax:307-742-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07108282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00710001OtherBCBS PROFESSIONAL
WY107332001Medicaid
WY107332008Medicaid
WY836000188OtherCHAMPUS
WY836000188OtherUNITED HEALTHCARE
WY007153OtherBCBS - INSTITUTIONAL
WY107332002Medicaid
WY836000188OtherGREAT WEST - WYOMING
WYW4251905OtherPTAN FOR PART B
WY107332000Medicaid
WY107332003Medicaid
CO95682704Medicaid
WY530025Medicare Oscar/Certification
WY107332003Medicaid