1700996576 NPI number — PHILIP M MARDEN MD SC

Table of content: (NPI 1700996576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700996576 NPI number — PHILIP M MARDEN MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP M MARDEN MD 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:
1700996576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 SUMMIT AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCONOMOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53066-3747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-567-0366
Provider Business Mailing Address Fax Number:
262-567-0368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 SUMMIT AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-3747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-567-0366
Provider Business Practice Location Address Fax Number:
262-567-0368
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARDEN
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
MANUEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
262-667-0366

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  14664 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 14664 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 14664 , 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: AS68366510001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112760524654 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 31212300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 718112 . This is a "MANAGED HEALTH SERVICES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 14664 . This is a "MEDICAL LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1200110 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52D0388538 . This is a "CLIA CERTIFICATE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1000283 . This is a "PHYSICIANS PLUS INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12659 . This is a "DEAN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 213688 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4308968 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: W003437 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: MARDENPHI . This is a "MERCYCARE HEALTH PLANS" identifier . This identifiers is of the category "OTHER".




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