1225168891 NPI number — MS. JEAN MARIE PRUSCHA CSAC, ICS

Table of content: MS. JEAN MARIE PRUSCHA CSAC, ICS (NPI 1225168891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225168891 NPI number — MS. JEAN MARIE PRUSCHA CSAC, ICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUSCHA
Provider First Name:
JEAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CSAC, ICS
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:
1225168891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N3157 WILLIAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE GENEVA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53147-3532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-249-0382
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RACINE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53403-1566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-634-8688
Provider Business Practice Location Address Fax Number:
262-634-7547
Provider Enumeration Date:
03/06/2007

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: 101YA0400X , with the licence number:  11083-132 , 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: 39389200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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