1417934308 NPI number — MRS. PATRICIA M. VAN DEN KIEBOOM OTR

Table of content: MRS. PATRICIA M. VAN DEN KIEBOOM OTR (NPI 1417934308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417934308 NPI number — MRS. PATRICIA M. VAN DEN KIEBOOM OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DEN KIEBOOM
Provider First Name:
PATRICIA
Provider Middle Name:
M.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1417934308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 N. PORT WASHINGTON RD.
Provider Second Line Business Mailing Address:
C/O ST. FRANCIS CHILDREN'S CENTER
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-351-8850
Provider Business Mailing Address Fax Number:
414-351-8846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6700 N. PORT WASHINGTON RD.
Provider Second Line Business Practice Location Address:
C/O ST. FRANCIS CHILDREN'S CENTER
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-351-8850
Provider Business Practice Location Address Fax Number:
414-351-8846
Provider Enumeration Date:
12/30/2005

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: 225X00000X , with the licence number:  3263-026 , 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: 40862700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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