1598125072 NPI number — BRITTANY N R BLOMBERG D.O.

Table of content: BRITTANY N R BLOMBERG D.O. (NPI 1598125072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598125072 NPI number — BRITTANY N R BLOMBERG D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOMBERG
Provider First Name:
BRITTANY
Provider Middle Name:
N R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLOMBERG
Provider Other First Name:
BRITTANY
Provider Other Middle Name:
NOEL ROWE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598125072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BELOIT HEALTH SYSTEM INC.
Provider Second Line Business Mailing Address:
1905 E. HUEBBE PARKWAY
Provider Business Mailing Address City Name:
BELOIT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53511-1842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-364-2293
Provider Business Mailing Address Fax Number:
608-364-5452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BELOIT CLINIC
Provider Second Line Business Practice Location Address:
1905 E. HUEBBE PARKWAY
Provider Business Practice Location Address City Name:
BELOIT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53511-1842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-364-2240
Provider Business Practice Location Address Fax Number:
608-363-7374
Provider Enumeration Date:
02/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 69203-21 , 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: 100103647 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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