1457396970 NPI number — PAUL S SANTARELLI PA

Table of content: PAUL S SANTARELLI PA (NPI 1457396970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457396970 NPI number — PAUL S SANTARELLI PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANTARELLI
Provider First Name:
PAUL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1457396970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3077 N MAYFAIR RD STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53222-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-384-6700
Provider Business Mailing Address Fax Number:
414-727-1058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 W RAWSON AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53132-9417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-325-4320
Provider Business Practice Location Address Fax Number:
414-761-1921
Provider Enumeration Date:
06/18/2006

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: 363A00000X , with the licence number:  1980 , 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: 42886100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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