1366433815 NPI number — COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366433815 NPI number — COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, 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:
NEWPORT PHARMACY
Provider Other Organization Name Type Code:
3
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:
1366433815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 N PORT WASHINGTON RD
Provider Second Line Business Mailing Address:
ATTN: CSMCP CLINIC CREDENTIALING
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-1082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-291-1303
Provider Business Mailing Address Fax Number:
414-278-2809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2015 E NEWPORT AVE
Provider Second Line Business Practice Location Address:
STE M121
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-2984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-961-3464
Provider Business Practice Location Address Fax Number:
414-961-5378
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
414-270-4850

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  8525-042 , 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: 33213400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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