Provider Demographics
NPI:1861590986
Name:CHILDERS, ADAM W (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:W
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435
Mailing Address - Country:US
Mailing Address - Phone:307-754-3313
Mailing Address - Fax:307-754-7448
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-754-3313
Practice Address - Fax:307-754-7448
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC924207Q00000X
MT11686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011003062Medicare PIN
SCI51416Medicare UPIN
SC151416Medicare UPIN