Provider Demographics
NPI:1992744817
Name:WIND RIVER OBSTETRICS AND GYNECOLOGY LLC
Entity type:Organization
Organization Name:WIND RIVER OBSTETRICS AND GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARYANNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANNANEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-857-3488
Mailing Address - Street 1:1005 COLLEGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2289
Mailing Address - Country:US
Mailing Address - Phone:307-856-4232
Mailing Address - Fax:307-856-4243
Practice Address - Street 1:1005 COLLEGE VIEW DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2266
Practice Address - Country:US
Practice Address - Phone:307-857-5217
Practice Address - Fax:307-857-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6798A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118601900Medicaid
WY9817Medicare ID - Type Unspecified
WY118601900Medicaid