1790158368 NPI number — WISCONSIN VISITING PODIATRY

Table of content: DR. TYLER LEE MAXEY DC (NPI 1902334345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790158368 NPI number — WISCONSIN VISITING PODIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISCONSIN VISITING PODIATRY
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:
1790158368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 187
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53185-0187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-444-3132
Provider Business Mailing Address Fax Number:
877-636-1498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28606 SANDPIPER TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53185-1733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-234-7304
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
262-444-3132

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43221600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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