1619192150 NPI number — JOHN R VAN SUSTEREN PT

Table of content: JOHN R VAN SUSTEREN PT (NPI 1619192150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619192150 NPI number — JOHN R VAN SUSTEREN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN SUSTEREN
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1619192150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 GENEVA PKWY N
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
LAKE GENEVA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53147-5701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-248-9902
Provider Business Mailing Address Fax Number:
262-248-9419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 GENEVA PKWY N
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
LAKE GENEVA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53147-5701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-248-9902
Provider Business Practice Location Address Fax Number:
262-248-9419
Provider Enumeration Date:
04/17/2007

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:  4467024 , 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: 40316500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11413052 . This is a "CAQH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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