1174931836 NPI number — DIRECT MEDICAL ACCESS SERVICES

Table of content: (NPI 1174931836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174931836 NPI number — DIRECT MEDICAL ACCESS SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIRECT MEDICAL ACCESS SERVICES
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:
1174931836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
638 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LAKE GENEVA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53147-1908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-215-9085
Provider Business Mailing Address Fax Number:
262-248-3801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
638 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAKE GENEVA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53147-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-215-9085
Provider Business Practice Location Address Fax Number:
262-248-3801
Provider Enumeration Date:
07/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KLIPP
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER ADMINISTRATOR
Authorized Official Telephone Number:
262-903-4455

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  100032541 , 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: 100032541 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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