1497889794 NPI number — JUDITH LORRAINE SOUTHER OTR

Table of content: JUDITH LORRAINE SOUTHER OTR (NPI 1497889794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497889794 NPI number — JUDITH LORRAINE SOUTHER OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHER
Provider First Name:
JUDITH
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMON
Provider Other First Name:
JUDITH
Provider Other Middle Name:
LORRAINE
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:
1497889794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1511 BRANSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55108-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-644-4086
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 ENLOE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016-8173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-386-2128
Provider Business Practice Location Address Fax Number:
715-386-6119
Provider Enumeration Date:
03/16/2007

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: 225X00000X , with the licence number:  4141 , 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: 40872200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7689529 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 641671046996 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 98G59SO . This is a "BCBS MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP43837 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6404305 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




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