1245458140 NPI number — MISS TAMMIE EILEEN DEMICCO COTA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245458140 NPI number — MISS TAMMIE EILEEN DEMICCO COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMICCO
Provider First Name:
TAMMIE
Provider Middle Name:
EILEEN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

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:
1245458140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 WILDWOOD CT UNIT D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMS BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53191-9647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-245-0219
Provider Business Mailing Address Fax Number:
262-728-7129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1922 COUNTY RD. NN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHORN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-741-3630
Provider Business Practice Location Address Fax Number:
262-743-1855
Provider Enumeration Date:
04/23/2007

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: 224Z00000X , with the licence number:  1812-027 , 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: 40850800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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