1124337043 NPI number — JILL M GREVENOW NP

Table of content: JILL M GREVENOW NP (NPI 1124337043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124337043 NPI number — JILL M GREVENOW NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREVENOW
Provider First Name:
JILL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLANDER
Provider Other First Name:
JILL
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124337043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 N 92ND ST
Provider Second Line Business Mailing Address:
PEDIATRIC SPECIAL NEEDS
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-4875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-337-7158
Provider Business Mailing Address Fax Number:
414-266-2926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 N 92ND ST
Provider Second Line Business Practice Location Address:
PEDIATRIC SPECIAL NEEDS
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-4875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-337-7158
Provider Business Practice Location Address Fax Number:
414-266-2926
Provider Enumeration Date:
09/27/2010

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: 363LP0200X , with the licence number:  147817 , 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: 1124337043 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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