Provider Demographics
NPI:1902803158
Name:CHEYENNE MEDICAL PLAZA SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:CHEYENNE MEDICAL PLAZA SURGERY CENTER, LLC
Other - Org Name:YELLOWSTONE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAKE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PULLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-635-7070
Mailing Address - Street 1:2301 HOUSE AVE
Mailing Address - Street 2:#200
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3176
Mailing Address - Country:US
Mailing Address - Phone:307-635-7070
Mailing Address - Fax:307-433-9311
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:#200
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-635-7070
Practice Address - Fax:307-433-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-186261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9508Medicare ID - Type UnspecifiedPROVIDER NUMBER