1487703880 NPI number — WISCONSIN INSTITUTE OF PLASTIC SURGERY SC

Table of content: (NPI 1487703880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487703880 NPI number — WISCONSIN INSTITUTE OF PLASTIC SURGERY SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISCONSIN INSTITUTE OF PLASTIC SURGERY 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:
6
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:
1487703880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 DICKINSON RD STE 17B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE PERE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54115-4056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-965-1234
Provider Business Mailing Address Fax Number:
920-965-1232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 E ENTERPRISE AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLETON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54913-7656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-965-1234
Provider Business Practice Location Address Fax Number:
920-965-1232
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JUSTUS
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
920-965-1234

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3677500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com