1770760480 NPI number — CARDIAC DIAGNOSTIC CLINIC, LTD

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 1770760480 NPI number — CARDIAC DIAGNOSTIC CLINIC, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIAC DIAGNOSTIC CLINIC, LTD
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:
1770760480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 210918
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-251-8447
Provider Business Mailing Address Fax Number:
262-251-5193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 W LAYTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-251-8447
Provider Business Practice Location Address Fax Number:
262-251-5193
Provider Enumeration Date:
01/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MARCHESE
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
262-251-8447

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  23216 , 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: 30359100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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