1255593117 NPI number — JILL MARIE SCHUESSLER RDH

Table of content: JILL MARIE SCHUESSLER RDH (NPI 1255593117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255593117 NPI number — JILL MARIE SCHUESSLER RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHUESSLER
Provider First Name:
JILL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MLADA
Provider Other First Name:
JILL
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RDH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255593117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
888 WORCESTER ST
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
WELLESLEY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02482-3744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-964-6681
Provider Business Mailing Address Fax Number:
339-686-2561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-964-6681
Provider Business Practice Location Address Fax Number:
888-662-0859
Provider Enumeration Date:
07/01/2008

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: 124Q00000X , with the licence number:  3143-016 , 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: 33827800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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