1417036005 NPI number — CHRISTIAN O DEBRANIN MD

Table of content: CHRISTIAN O DEBRANIN MD (NPI 1417036005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417036005 NPI number — CHRISTIAN O DEBRANIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEBRANIN
Provider First Name:
CHRISTIAN
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1417036005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 WEST AVE S
Provider Second Line Business Mailing Address:
PHYSICIAN SERVICES DEPT
Provider Business Mailing Address City Name:
LA CROSSE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54601-4783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-392-4156
Provider Business Mailing Address Fax Number:
608-392-9898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 WEST AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54601-8806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-392-9510
Provider Business Practice Location Address Fax Number:
608-392-9860
Provider Enumeration Date:
11/03/2006

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: 207RH0003X , with the licence number:  45184 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0003X , with the licence number: 27870 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 34311000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000220347 . This is a "ANTHEM BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 6427870800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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