1851334395 NPI number — JONATHAN R HAYWARD PAC

Table of content: JONATHAN R HAYWARD PAC (NPI 1851334395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851334395 NPI number — JONATHAN R HAYWARD PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAYWARD
Provider First Name:
JONATHAN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

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:
1851334395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54220-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-663-9008
Provider Business Mailing Address Fax Number:
920-684-1439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 MURRAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARINETTE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54143-3367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-732-0699
Provider Business Practice Location Address Fax Number:
715-732-3522
Provider Enumeration Date:
06/13/2006

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: 363A00000X , with the licence number:  1593-23 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: 1593023 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 41946800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1593-023 . This is a "STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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