1083681407 NPI number — PAUL E NIEMUTH PT,DSC,OCS,SCS,ATC

Table of content: PAUL E NIEMUTH PT,DSC,OCS,SCS,ATC (NPI 1083681407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083681407 NPI number — PAUL E NIEMUTH PT,DSC,OCS,SCS,ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIEMUTH
Provider First Name:
PAUL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT,DSC,OCS,SCS,ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083681407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 52ND ST STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53140-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-925-5000
Provider Business Mailing Address Fax Number:
262-925-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 ASH ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
SPOONER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54801-1487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-635-2518
Provider Business Practice Location Address Fax Number:
866-245-8064
Provider Enumeration Date:
03/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1739 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1811-024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11363195 . This is a "CAQH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1083681407 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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