1063464337 NPI number — CAROLYN T MCCARTHY NP

Table of content: CAROLYN T MCCARTHY NP (NPI 1063464337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063464337 NPI number — CAROLYN T MCCARTHY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCARTHY
Provider First Name:
CAROLYN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1063464337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
3-262-2508
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 W BRUCE ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53204-1667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-384-1400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2006

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: 363L00000X , with the licence number:  4704216109 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 13525-33 , 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: 100014626 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4850425 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4850407 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4850416 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700D114790 . This is a "BCBS GROUP #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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