1508940255 NPI number — COMPREHENSIVE GENETIC SERVICES, SC

Table of content: (NPI 1508940255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508940255 NPI number — COMPREHENSIVE GENETIC SERVICES, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE GENETIC SERVICES, SC
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:
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:
1508940255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3720 N 124TH ST
Provider Second Line Business Mailing Address:
SUITE I
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53222-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-393-1000
Provider Business Mailing Address Fax Number:
414-393-1399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3720 N 124TH ST
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53222-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-393-1000
Provider Business Practice Location Address Fax Number:
414-393-1399
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRYKE
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
414-393-1000

Provider Taxonomy Codes

  • Taxonomy code: 207SC0300X , with the licence number:  33237 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207SG0201X , with the licence number: 33237 , 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: 32516200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2132702001 . This is a "AMERICHOICE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 120003406 . This is a "WEA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 5241745 . This is a "AETNA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 6344590 . This is a "ABRI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32516200 . This is a "MANAGED HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 7400178 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 072446202 . This is a "TRICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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