1497778278 NPI number — JESSICA A. EDELMANN MPT

Table of content: SUZANNE BARRETT-MCCLENDON LIMHP (NPI 1841282928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497778278 NPI number — JESSICA A. EDELMANN MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDELMANN
Provider First Name:
JESSICA
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHULTE
Provider Other First Name:
JESSICA
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497778278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 N PROVIDENCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54913-8018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-257-2009
Provider Business Mailing Address Fax Number:
920-257-2004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 2ND AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54806-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-685-9656
Provider Business Practice Location Address Fax Number:
715-685-9544
Provider Enumeration Date:
07/25/2006

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: 225100000X , with the licence number:  10413-024 , 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: P00281530 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40452300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111200 . This is a "SECURITY HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 484R6ED . This is a "GROUP HEALTH/BCBS OF MN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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