Provider Demographics
NPI:1912102989
Name:FITZSIMMONS, BRENDAN H (MD)
Entity type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:H
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:BIG PINEY
Mailing Address - State:WY
Mailing Address - Zip Code:83113-0787
Mailing Address - Country:US
Mailing Address - Phone:307-276-3306
Mailing Address - Fax:307-276-3024
Practice Address - Street 1:103 W 3RD ST.
Practice Address - Street 2:
Practice Address - City:MARBLETON
Practice Address - State:WY
Practice Address - Zip Code:83113
Practice Address - Country:US
Practice Address - Phone:307-276-3306
Practice Address - Fax:307-276-3024
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY6031-A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY53Z301Medicare Oscar/Certification
WY535019Medicare Oscar/Certification
WY533981Medicare Oscar/Certification
WY531301Medicare Oscar/Certification
WYG29995Medicare UPIN