1033215835 NPI number — WATERTOWN INTERNAL MEDICINE SC

Table of content: (NPI 1033215835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033215835 NPI number — WATERTOWN INTERNAL MEDICINE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERTOWN INTERNAL MEDICINE SC
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:
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:
1033215835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53094-0110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-262-4784
Provider Business Mailing Address Fax Number:
920-262-4640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 2009
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53098-3331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-262-9833
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLUGE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PATIENT ACCOUNTING MANAGER
Authorized Official Telephone Number:
920-262-4784

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21267100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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