1275976979 NPI number — ACCENTCARE MEDICAL GROUP OF WISCONSIN, S.C.

Table of content: (NPI 1275976979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275976979 NPI number — ACCENTCARE MEDICAL GROUP OF WISCONSIN, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACCENTCARE MEDICAL GROUP OF WISCONSIN, S.C.
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:
SEASONS MEDICAL GROUP OF WISCONSIN, SC
Provider Other Organization Name Type Code:
4
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:
1275976979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 SHAFER CT STE 300A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEMONT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60018-4914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-692-1000
Provider Business Mailing Address Fax Number:
224-532-2780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6737 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE 2150
Provider Business Practice Location Address City Name:
WEST ALLIS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53214-5647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-379-5105
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BILL
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE DIRECTOR
Authorized Official Telephone Number:
847-692-1148

Provider Taxonomy Codes

  • Taxonomy code: 207QH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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