1053319285 NPI number — METZ MEDICAL INC

Table of content: BRADLEY W. BASE M.A. (NPI 1710944905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053319285 NPI number — METZ MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METZ MEDICAL 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's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1053319285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2045 LATHROP AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RACINE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53405-3758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-654-4000
Provider Business Mailing Address Fax Number:
262-654-5400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2045 LATHROP AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RACINE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53405-3758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-654-4000
Provider Business Practice Location Address Fax Number:
262-654-5400
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPLIANCE OPERATIONS SUPERVISOR
Authorized Official Telephone Number:
440-735-3096

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: 2097-028 , 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: 41694800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9408-40 . This is a "DSPS - PHARMACY EXAMINING BOARD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1297-045 . This is a "DEPT REG/LIC - DISTRIBUTO" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 315-044 . This is a "DEPT OF REG/LIC - MANUFAC" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 203.001469 . This is a "DEPT OF FINAN & PROF REG - HME & SERVICES PROVIDER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 040018300 . This is a "FEDERAL BLACK PROGRAM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2556-45 . This is a "DEPT REG/LIC - DISTRIBUTOR OF PRESC DRUGS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 2097-028 . This is a "DEPT REG/LIC- RESP CARE P" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 8009-042 . This is a "DEPT REG/LIC- PHARMACY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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