1336204643 NPI number — DR. CHARLES ALBERT HUIBREGTSE MD PHD

Table of content: DR. CHARLES ALBERT HUIBREGTSE MD PHD (NPI 1336204643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336204643 NPI number — DR. CHARLES ALBERT HUIBREGTSE MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUIBREGTSE
Provider First Name:
CHARLES
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1336204643
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 900
Provider Second Line Business Mailing Address:
1600 COUNTY RD EE
Provider Business Mailing Address City Name:
REDGRANITE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54970-0900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-566-3167
Provider Business Mailing Address Fax Number:
920-566-3166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 COUNTY RD EE
Provider Second Line Business Practice Location Address:
REDGRANITE CORRECTIONAL INSTITUTION
Provider Business Practice Location Address City Name:
REDGRANITE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54970-0900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-566-3167
Provider Business Practice Location Address Fax Number:
920-566-3166
Provider Enumeration Date:
12/27/2006

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: 207Q00000X , with the licence number:  41116-020 , 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)





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