1588963508 NPI number — EYE PHYSICIAN ASSOCIATES, S.C.

Table of content: (NPI 1588963508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588963508 NPI number — EYE PHYSICIAN ASSOCIATES, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE PHYSICIAN ASSOCIATES, 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:
EYE PHYSICIAN ASSOCIATES, S.C.
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:
1588963508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 W KK RIVER PKWY
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53215-3669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-385-8725
Provider Business Mailing Address Fax Number:
414-385-8730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 W KK RIVER PKWY
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215-3669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-385-8725
Provider Business Practice Location Address Fax Number:
414-385-8730
Provider Enumeration Date:
03/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RISSELL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-385-8725

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32306500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31912700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38632200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34678800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30934200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32735700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34249800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: C017777 . This is a "RR MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 000073822 . This is a "MILWAUKEE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1851590343 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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