1518079771 NPI number — PARKLAND FAMILY PHYSICIANS SC

Table of content: (NPI 1518079771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518079771 NPI number — PARKLAND FAMILY PHYSICIANS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKLAND FAMILY PHYSICIANS 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:
1518079771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4448 W LOOMIS ROAD
Provider Second Line Business Mailing Address:
SUITE #101
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53220-4817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-282-4443
Provider Business Mailing Address Fax Number:
414-282-2278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4448 W LOOMIS ROAD
Provider Second Line Business Practice Location Address:
SUITE #101
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53220-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-282-4443
Provider Business Practice Location Address Fax Number:
414-282-2278
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NIMMER
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
414-282-4443

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  29409 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 29494 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 32767900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: W010282 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".