1104071653 NPI number — JOSEPH H CANNARIATO MSOM, BSN, LAC, CAC

Table of content: JOSEPH H CANNARIATO MSOM, BSN, LAC, CAC (NPI 1104071653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104071653 NPI number — JOSEPH H CANNARIATO MSOM, BSN, LAC, CAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNARIATO
Provider First Name:
JOSEPH
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSOM, BSN, LAC, CAC
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:
1104071653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10600 W BLUEMOUND RD
Provider Second Line Business Mailing Address:
STE 1 @ EVOLUTION REHAB
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-4254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-258-2090
Provider Business Mailing Address Fax Number:
419-791-6608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10600 W BLUEMOUND RD
Provider Second Line Business Practice Location Address:
STE 1 @ EVOLUTION REHAB
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-4254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-258-2090
Provider Business Practice Location Address Fax Number:
419-791-6608
Provider Enumeration Date:
11/25/2008

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: 171100000X , with the licence number:  601-055 , 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)





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