Provider Demographics
NPI:1528113180
Name:SHERIDAN NEUROLOGY PC
Entity type:Organization
Organization Name:SHERIDAN NEUROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:REENE
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-673-6300
Mailing Address - Street 1:1050 MYDLAND RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2186
Mailing Address - Country:US
Mailing Address - Phone:307-673-6300
Mailing Address - Fax:307-673-6303
Practice Address - Street 1:1050 MYDLAND RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2186
Practice Address - Country:US
Practice Address - Phone:307-673-6300
Practice Address - Fax:307-673-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6950A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY148019300OtherFEDERAL WORKERS COMP
WI5696001OtherWY BLUE SHIELD
WY119441100Medicaid
WY120469600Medicaid
P00184005Medicare ID - Type UnspecifiedRR MEDICARE INDIVIDUAL
DC6874Medicare ID - Type UnspecifiedRR MEDICARE GROUP
WY148019300OtherFEDERAL WORKERS COMP
WY119441100Medicaid
WY120469600Medicaid