1477981942 NPI number — SPECTRUM HEALTH MEDICAL CLINIC, LLC

Table of content: (NPI 1477981942)

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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