Provider Demographics
NPI:1487765764
Name:UROLOGY CLINIC PC
Entity type:Organization
Organization Name:UROLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:H
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-745-3097
Mailing Address - Street 1:2710 HARNEY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-2899
Mailing Address - Country:US
Mailing Address - Phone:307-745-3097
Mailing Address - Fax:307-745-7431
Practice Address - Street 1:2710 HARNEY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-2899
Practice Address - Country:US
Practice Address - Phone:307-745-3097
Practice Address - Fax:307-745-7431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5981A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106684600Medicaid
WYW307482Medicare PIN
WY106684600Medicaid
WYW307482Medicare PIN