Provider Demographics
NPI:1780076364
Name:EVANSTON REGIONAL HOSPITAL
Entity type:Organization
Organization Name:EVANSTON REGIONAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-789-3636
Mailing Address - Street 1:531 PARKWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:WY
Mailing Address - Zip Code:82939
Mailing Address - Country:US
Mailing Address - Phone:307-782-7560
Mailing Address - Fax:
Practice Address - Street 1:531 PARKWAY DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:WY
Practice Address - Zip Code:82939
Practice Address - Country:US
Practice Address - Phone:307-782-7560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY33582.1375261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care