1467486522 NPI number — DR. MARK A MICHAEL DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467486522 NPI number — DR. MARK A MICHAEL DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICHAEL
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1467486522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 N CALHOUN RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53005-5902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-785-1233
Provider Business Mailing Address Fax Number:
262-785-1258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 N CALHOUN RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-785-1233
Provider Business Practice Location Address Fax Number:
262-785-1258
Provider Enumeration Date:
07/11/2006

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: 111N00000X , with the licence number:  1918012 , 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: 201994442014 . This is a "BCBS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 402681 . This is a "WI EMPL. ID" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38838100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 606473100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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