NPIMap

Organization Active NPI

Evanston Clinic Corp

  • Family Medicine Physician
  • Evanston, WY
National Provider Identifier
1013916519
Registry record updated Mar 4, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
EVANSTON CLINIC CORP
Practice address
196 Arrowhead Dr Ste 8
Evanston, WY 82930-8752
Phone
(307) 783-8365
Fax
(307) 783-8284
NPI assigned
Jul 18, 2005
Last updated
Mar 4, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Laura J Fey
Title
Director Revenue Cycle
Phone
(615) 221-3641

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Medical Physician Assistant 363AM0700X
Family Nurse Practitioner 363LF0000X
Family Medicine Physician 207Q00000X WY Primary
Internal Medicine Physician 207R00000X WY
Obstetrics & Gynecology Physician 207V00000X WY
Surgery Physician 208600000X WY
Urology Physician 208800000X WY
General Practice Physician 208D00000X

Addresses

Primary practice location

196 Arrowhead Dr Ste 8
Evanston, WY 82930-8752

Mailing address

PO Box 5009
Brentwood, TN 37024-5009
Phone (615) 221-1400

Other identifiers 2

IdentifierTypeStateIssuer
1013916519MedicaidWY
06159001OtherWYBCBS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040514000481 WY Part B Supplier - Clinic/Group Practice 8325038094 Receives reassigned benefits from 40 practitioners
Practice locations: Mountain View, WY; Lyman, WY; Evanston, WY; Diamondville, WY

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
53D0951953Evanston Clinic Corp196 Arrowhead Drive, Ste #1, Evanston, WY 82930Certificate of waiverJul 15, 2027

National Provider Directory

National Provider Directory

Locations

150 Arrowhead Dr
Ste 1
Evanston, WY 82930
Phone (307) 789-0524

150 Arrowhead Dr
Ste 2
Evanston, WY 82930
Phone (307) 789-5080

195 Overthrust Rd
Evanston, WY 82930
Phone (307) 444-3600

196 Arrowhead Dr
Ste 1
Evanston, WY 82930
Phone (307) 783-8123

196 Arrowhead Dr
Ste 2
Evanston, WY 82930
Phone (307) 783-8143

196 Arrowhead Dr
Ste 4
Evanston, WY 82930
Phone (307) 789-8721

196 Arrowhead Dr
Ste 6
Evanston, WY 82930
Phone (307) 783-8361

196 Arrowhead Dr
Ste 9
Evanston, WY 82930
Phone (307) 783-8280

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 58

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 58

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121644800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1551657600000",
    "number": "1013916519",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5009",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370245009",
            "telephone_number": "615-221-1400",
            "fax_number": "615-465-2984"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "196 ARROWHEAD DR STE 8",
            "city": "EVANSTON",
            "state": "WY",
            "postal_code": "829308752",
            "telephone_number": "307-783-8365",
            "fax_number": "307-783-8284"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVANSTON CLINIC CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-18",
        "last_updated": "2019-03-04",
        "status": "A",
        "authorized_official_last_name": "FEY",
        "authorized_official_first_name": "LAURA",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "DIRECTOR REVENUE CYCLE",
        "authorized_official_telephone_number": "615-221-3641"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WY",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "WY",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "WY",
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "WY",
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "WY",
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1013916519",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "06159001",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Evanston, WY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.