1174955900 NPI number — MS. AMY R MAGER PAC

Table of content: MS. AMY R MAGER PAC (NPI 1174955900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174955900 NPI number — MS. AMY R MAGER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAGER
Provider First Name:
AMY
Provider Middle Name:
R
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RANKIN
Provider Other First Name:
AMY
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174955900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9200 W WISCONSIN AVE
Provider Second Line Business Mailing Address:
NEOPLASTIC DISEASES
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-805-6800
Provider Business Mailing Address Fax Number:
414-805-1514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9200 W WISCONSIN AVE
Provider Second Line Business Practice Location Address:
NEOPLASTIC DISEASES
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-805-6800
Provider Business Practice Location Address Fax Number:
414-805-1514
Provider Enumeration Date:
08/03/2013

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: 363AM0700X , with the licence number:  3128 - 23 , 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: 1174955900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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