1669635868 NPI number — MARGARET I SCOTTBERG PA

Table of content: MARGARET I SCOTTBERG PA (NPI 1669635868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669635868 NPI number — MARGARET I SCOTTBERG PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTTBERG
Provider First Name:
MARGARET
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILGENBACH
Provider Other First Name:
MARGARET
Provider Other Middle Name:
I
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669635868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2014
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:
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:
414-326-2218
Provider Business Mailing Address Fax Number:
414-326-2208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 N LAKE DR RM 1577
Provider Second Line Business Practice Location Address:
COLUMBIA ST MARY'S MS CLINIC
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-291-1771
Provider Business Practice Location Address Fax Number:
414-291-1781
Provider Enumeration Date:
07/08/2008

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: 363AS0400X , with the licence number:  2298-23 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 2298 , 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: 2298-23 . This is a "STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".