1225244668 NPI number — ELIZABETH POLACHECK MD SC

Table of content: (NPI 1225244668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225244668 NPI number — ELIZABETH POLACHECK MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH POLACHECK MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1225244668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3033 W LAYTON AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-2621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-727-8199
Provider Business Mailing Address Fax Number:
888-371-8009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 W LAYTON AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-727-8199
Provider Business Practice Location Address Fax Number:
888-371-8009
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POLACHECK
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
414-727-8199

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 32041800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com