Provider Demographics
NPI:1700123288
Name:GANNETT PEAK PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:GANNETT PEAK PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-335-4104
Mailing Address - Street 1:745 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3431
Mailing Address - Country:US
Mailing Address - Phone:307-335-4104
Mailing Address - Fax:
Practice Address - Street 1:745 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3431
Practice Address - Country:US
Practice Address - Phone:307-335-4104
Practice Address - Fax:307-335-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty