1205892486 NPI number — BRADLEY A TYTHCOTT PT

Table of content: BRADLEY A TYTHCOTT PT (NPI 1205892486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205892486 NPI number — BRADLEY A TYTHCOTT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYTHCOTT
Provider First Name:
BRADLEY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1205892486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 QUINLAN DR
Provider Second Line Business Mailing Address:
UNIT G
Provider Business Mailing Address City Name:
PEWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53072-1809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-746-9785
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N53W24950 S CORPORATE CIR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SUSSEX
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53089-4374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
126-224-6300
Provider Business Practice Location Address Fax Number:
262-246-4255
Provider Enumeration Date:
04/25/2006

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: 225100000X , with the licence number:  9592 , 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: 40465300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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