1114956232 NPI number — DR. ANNA MARIA MYKLEBUST MD

Table of content: DR. ANNA MARIA MYKLEBUST MD (NPI 1114956232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114956232 NPI number — DR. ANNA MARIA MYKLEBUST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYKLEBUST
Provider First Name:
ANNA
Provider Middle Name:
MARIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MYKLEBUST
Provider Other First Name:
ANNA MARIA
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1114956232
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W8919 RIPLEY RD
Provider Second Line Business Mailing Address:
P.O. 629
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53523-9011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-423-7400
Provider Business Mailing Address Fax Number:
608-423-7400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W8919 RIPLEY RD
Provider Second Line Business Practice Location Address:
P.O. 629
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53523-9011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-423-7400
Provider Business Practice Location Address Fax Number:
608-423-7400
Provider Enumeration Date:
07/01/2006

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: 2085R0202X , with the licence number:  34650-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 51515 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 38149 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 300088211 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 3195200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391128616RU . This is a "JOHN DEERE HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4873 . This is a "DEAN HEALTH INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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