1275542607 NPI number — WEST BEND CLINIC

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 1275542607 NPI number — WEST BEND CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST BEND CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JACKSON CLINIC
Provider Other Organization Name Type Code:
5
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:
1275542607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 W PARADISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BEND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53095-9795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-334-3451
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W225N16711 CEDAR PARK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53037-9222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-677-1101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLOMMEL
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
262-334-3451

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 21251400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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