1457402307 NPI number — GARLAND W YARBOROUGH, MD SC

Table of content: (NPI 1457402307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457402307 NPI number — GARLAND W YARBOROUGH, MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARLAND W YARBOROUGH, MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1457402307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
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
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MILWAUKEE
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:
414-771-5900
Provider Business Mailing Address Fax Number:
414-771-4908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3077 N MAYFAIR RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53222-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-771-5900
Provider Business Practice Location Address Fax Number:
414-771-4908
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YARBOROUGH
Authorized Official First Name:
GARLAND
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
414-771-5900

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  23313020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RG0100X , with the licence number: 23313020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 30323500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23313020 . This is a "STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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