1023136512 NPI number — SUSAN KAY BOLAND P.A.

Table of content: SUSAN KAY BOLAND P.A. (NPI 1023136512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023136512 NPI number — SUSAN KAY BOLAND P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLAND
Provider First Name:
SUSAN
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PENDELL-ROGERS
Provider Other First Name:
SUSAN
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023136512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 E. HUEBBE PARKWAY
Provider Second Line Business Mailing Address:
BELOIT HEALTH SYSTEM INC
Provider Business Mailing Address City Name:
BELOIT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53511-1842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-364-2200
Provider Business Mailing Address Fax Number:
608-363-7395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 NORTH WASHINGTON STREET
Provider Second Line Business Practice Location Address:
DARIEN MEDICAL CLINIC
Provider Business Practice Location Address City Name:
DARIEN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53114-1534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-882-1151
Provider Business Practice Location Address Fax Number:
262-296-1195
Provider Enumeration Date:
03/26/2007

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: 363A00000X , with the licence number:  085001543 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 2122-23 , 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: 1023136512 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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