1992846836 NPI number — SPECIALIZED MEDICAL SERVICES, INC.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992846836 NPI number — SPECIALIZED MEDICAL SERVICES, INC.

Employer Identification Number (EIN):

Provider Organization Name:

SPECIALIZED MEDICAL SERVICES, INC.

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1992846836

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

12/30/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

5343 N 118TH CT

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:

53225-3085

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

414-476-1112

Provider Business Mailing Address Fax Number:

414-476-6118

Provider First Line Business Practice Location Address:

2875 S 171ST ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

NEW BERLIN

Provider Business Practice Location Address State Name:

WI

Provider Business Practice Location Address Postal Code:

53151-3511

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

414-476-1112

Provider Business Practice Location Address Fax Number:

414-476-6118

Provider Enumeration Date:

02/12/2007

Authorized Official Last Name:

MCCARTHY

Authorized Official First Name:

GREGORY

Authorized Official Middle Name:

Authorized Official Title or Position:

CHIEF OPERATIONS OFFICER

Authorized Official Telephone Number:

727-530-7700

• Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 51264 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 906662 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
• Identifier: 200479890 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 120638900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
• Identifier: 93022557 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
• Identifier: 100505103 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
• Identifier: 4568192 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 41709300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 807398300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 9056573 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1715138 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 2478457 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: DM1182 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".