1477981942 NPI number — SPECTRUM HEALTH MEDICAL CLINIC, LLC

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 1477981942 NPI number — SPECTRUM HEALTH MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM HEALTH MEDICAL CLINIC, LLC
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:
1477981942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIENSVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092-0639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-247-9005
Provider Business Mailing Address Fax Number:
414-247-9004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W176N9830 RIVERCREST DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53022-4625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-324-0944
Provider Business Practice Location Address Fax Number:
414-921-5600
Provider Enumeration Date:
10/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
414-324-0944

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  53594 , 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: K100107570 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1902078801 . This is a "NPI INDIVIDUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: K400107593 . This is a "MEDICARE PTAN INDIVIDUAL" identifier . This identifiers is of the category "OTHER".




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