Provider Demographics
NPI:1356556518
Name:BRENT BLUE MD
Entity type:Organization
Organization Name:BRENT BLUE MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-733-8002
Mailing Address - Street 1:PO BOX 15240
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-5240
Mailing Address - Country:US
Mailing Address - Phone:307-733-8002
Mailing Address - Fax:307-733-0032
Practice Address - Street 1:982 W BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-8002
Practice Address - Fax:307-733-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3416A261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY218545001OtherUSDOL CLINIC NUMBER
WY109651600Medicaid
W305961Medicare PIN
WY218545001OtherUSDOL CLINIC NUMBER