1114270451 NPI number — MRS. KATHERINE SUE WISEHART MAC

Table of content: MRS. KATHERINE SUE WISEHART MAC (NPI 1114270451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114270451 NPI number — MRS. KATHERINE SUE WISEHART MAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISEHART
Provider First Name:
KATHERINE
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MAC
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:
1114270451
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22110 STATE HIGHWAY 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EWING
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63440-2629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-767-1212
Provider Business Mailing Address Fax Number:
573-767-1212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 EAST LAFAYETTE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-767-1212
Provider Business Practice Location Address Fax Number:
573-767-1212
Provider Enumeration Date:
10/24/2012

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: 101Y00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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