1558449009 NPI number — DR. AMY D CVENGROS M.D.

Table of content: DR. AMY D CVENGROS M.D. (NPI 1558449009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558449009 NPI number — DR. AMY D CVENGROS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CVENGROS
Provider First Name:
AMY
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAPERON
Provider Other First Name:
AMY
Provider Other Middle Name:
DIANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558449009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54305-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-445-7210
Provider Business Mailing Address Fax Number:
920-445-7289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 WOODWARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRON MOUNTAIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49801-4631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-776-9040
Provider Business Practice Location Address Fax Number:
906-774-5950
Provider Enumeration Date:
11/01/2006

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: 207R00000X , with the licence number:  51856 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301507438 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 711290211 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 450030815 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".