1124213871 NPI number — MRS. SUE LYN CONDON P.T.

Table of content: MRS. SUE LYN CONDON P.T. (NPI 1124213871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124213871 NPI number — MRS. SUE LYN CONDON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONDON
Provider First Name:
SUE
Provider Middle Name:
LYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLAZEK
Provider Other First Name:
SUE
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124213871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 387
Provider Second Line Business Mailing Address:
2817 NEW PINERY ROAD, SUITE 103
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-745-6211
Provider Business Mailing Address Fax Number:
608-745-6250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 NEW PINERY RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53901-9257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-745-6211
Provider Business Practice Location Address Fax Number:
608-745-6250
Provider Enumeration Date:
09/06/2007

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: 225100000X , with the licence number:  4741 , 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: 40240700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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