1952465783 NPI number — MISS SUSAN BEVERLY COLLYARD MA

Table of content: MISS SUSAN BEVERLY COLLYARD MA (NPI 1952465783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952465783 NPI number — MISS SUSAN BEVERLY COLLYARD MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLYARD
Provider First Name:
SUSAN
Provider Middle Name:
BEVERLY
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BATT
Provider Other First Name:
SUSAN
Provider Other Middle Name:
B.
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952465783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18453
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53218-0453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-617-1258
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4929 W FOND DU LAC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53216-2324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-871-6122
Provider Business Practice Location Address Fax Number:
414-871-2552
Provider Enumeration Date:
12/19/2006

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: 101Y00000X , with the licence number:  100-226 , 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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