1013006329 NPI number — MR. GEORGE PAUL THOTTAKARA MA CADC III

Table of content: MR. GEORGE PAUL THOTTAKARA MA CADC III (NPI 1013006329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013006329 NPI number — MR. GEORGE PAUL THOTTAKARA MA CADC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOTTAKARA
Provider First Name:
GEORGE
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA CADC III
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:
1013006329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 HALL AVE
Provider Second Line Business Mailing Address:
SUITE A MARINETTE COUNTY HEALTH AND HUMAN SERVICES
Provider Business Mailing Address City Name:
MARINETTE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-732-7760
Provider Business Mailing Address Fax Number:
715-732-7711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 JACKSON ST
Provider Second Line Business Practice Location Address:
MARINETTE COUNTY HEALTH AND HUMAN SERVICES
Provider Business Practice Location Address City Name:
NIAGARA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-251-4555
Provider Business Practice Location Address Fax Number:
715-251-1754
Provider Enumeration Date:
10/12/2006

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: 101YA0400X , with the licence number:  2579125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: 2579125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 2579125 . This is a "LICENSE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39187300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".