1912004516 NPI number — MADISON MENTAL HEALTH SERVICES

Table of content: (NPI 1912004516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912004516 NPI number — MADISON MENTAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON MENTAL HEALTH SERVICES
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:
SATELLITE OFFICE--715 HILL STREET, MADISON 53705
Provider Other Organization Name Type Code:
5
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:
1912004516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 N BLACKHAWK AVE
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53705-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-238-5535
Provider Business Mailing Address Fax Number:
608-238-7294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 HILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53705-3542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-238-5535
Provider Business Practice Location Address Fax Number:
608-238-7294
Provider Enumeration Date:
09/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGLOIN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
F
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
608-231-2008

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  91-123 , 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)





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