1912921859 NPI number — MR. JEROME A PRUSS RPH

Table of content: MR. JEROME A PRUSS RPH (NPI 1912921859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912921859 NPI number — MR. JEROME A PRUSS RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUSS
Provider First Name:
JEROME
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
M

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:
1912921859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3116 N OAKDALE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54914-6875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-735-1605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ZABLOCKI DEPARTMENT OF VETERAN AFFAIRS MEDICAL CTR
Provider Second Line Business Practice Location Address:
500 WEST NATIONAL AVENUE
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53295-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-384-2000
Provider Business Practice Location Address Fax Number:
414-389-4276
Provider Enumeration Date:
07/26/2006

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: 183500000X , with the licence number:  RP 033110 L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 12132-040 , 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)