Organization
ST JOHN'S SURGICAL GROUP, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL ROSENBERG MD (PRESIDENT)
(307) 733-0422
Entity
Organization
Contact information
Practice address
555 E BROADWAY AVE, SUITE 229, JACKSON, WY 83001-8640
(307) 733-0422
(307) 733-2580
Mailing address
PO BOX 4197, JACKSON, WY 83001-4197
(307) 733-0422
(307) 733-2580
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
5051A
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004294400
—
ID
05
—
101117100
—
WY
Enumeration date
12/27/2006
Last updated
09/25/2014
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