1952487506 NPI number — CARY J KOHLENBERG MD SC

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 1952487506 NPI number — CARY J KOHLENBERG MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARY J KOHLENBERG MD SC
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:
INDEPENDENT PSYCHIATRIC CONSULTANTS MENTAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1952487506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2717 N GRANDVIEW BLVD
Provider Second Line Business Mailing Address:
# 202
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-513-0700
Provider Business Mailing Address Fax Number:
262-513-0707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2717 N GRANDVIEW BLVD
Provider Second Line Business Practice Location Address:
# 202
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-513-0700
Provider Business Practice Location Address Fax Number:
262-513-0707
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOHLENBERG
Authorized Official First Name:
CARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
262-513-0700

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21300600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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