1942492020 NPI number — MRS. REBECCA ANN BURDETTE MS, PROFESSIONAL COU

Table of content: MRS. REBECCA ANN BURDETTE MS, PROFESSIONAL COU (NPI 1942492020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942492020 NPI number — MRS. REBECCA ANN BURDETTE MS, PROFESSIONAL COU

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURDETTE
Provider First Name:
REBECCA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, PROFESSIONAL COU
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POKROP
Provider Other First Name:
REBECCA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942492020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 60TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-654-5333
Provider Business Mailing Address Fax Number:
262-654-7818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 60TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-654-5333
Provider Business Practice Location Address Fax Number:
262-654-7818
Provider Enumeration Date:
08/13/2007

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: 103TH0004X , with the licence number:  240-226 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 240-226 , 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: 42133400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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