1114933660 NPI number — LYNN VIDAKOVIC MD

Table of content: LYNN VIDAKOVIC MD (NPI 1114933660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114933660 NPI number — LYNN VIDAKOVIC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDAKOVIC
Provider First Name:
LYNN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RADER
Provider Other First Name:
LYNN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114933660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2025
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:
800-326-2250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 W KK RIVER PKWY STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215-3660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-649-7708
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2006

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: 208100000X , with the licence number:  77097 , 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: 036114330 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1114933660 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00259786 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 100206256 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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