Provider Demographics
NPI:1386716710
Name:SOUTH LINCOLN HOSPITAL DISTRICT
Entity type:Organization
Organization Name:SOUTH LINCOLN HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-877-4401
Mailing Address - Street 1:711 ONYX ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3214
Mailing Address - Country:US
Mailing Address - Phone:307-877-4401
Mailing Address - Fax:307-877-3236
Practice Address - Street 1:711 ONYX ST
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101
Practice Address - Country:US
Practice Address - Phone:307-877-4401
Practice Address - Fax:307-877-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-148261Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00943001OtherBLUE CROSS
WY106769901Medicaid
WY830267172A001OtherCHAMPUS
WY830267172002OtherWORKER'S COMP
WY106769901Medicaid
WYCO3016Medicare PIN