1003924598 NPI number — LISA WENTWORTH-ROHR MA

Table of content: LISA WENTWORTH-ROHR MA (NPI 1003924598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003924598 NPI number — LISA WENTWORTH-ROHR MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENTWORTH-ROHR
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
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:
ROHR
Provider Other First Name:
RADHE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1003924598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11121 W NORTH AVE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-2233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-780-9788
Provider Business Mailing Address Fax Number:
414-443-2719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11121 W NORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-2233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-780-9788
Provider Business Practice Location Address Fax Number:
414-443-2719
Provider Enumeration Date:
08/26/2006

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: 1041C0700X , with the licence number:  3069123 , 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: 43579900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com