1285716308 NPI number — RAVENSWOOD CLINIC INC

Table of content: PATRICIA ANN JAWORSKI OTR (NPI 1225126238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285716308 NPI number — RAVENSWOOD CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAVENSWOOD CLINIC INC
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:
6
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:
1285716308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2266 N PROSPECT AVE
Provider Second Line Business Mailing Address:
SUITE 326
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53202-6306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-224-0492
Provider Business Mailing Address Fax Number:
414-224-8112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2266 N PROSPECT AVE
Provider Second Line Business Practice Location Address:
SUITE 608
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53202-6306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-224-0492
Provider Business Practice Location Address Fax Number:
414-224-8112
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WERTH
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
414-224-0492

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  2118 , 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: L12215600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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