1639294168 NPI number — NORTHWEST PASSAGE LTD

Table of content: (NPI 1639294168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639294168 NPI number — NORTHWEST PASSAGE LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST PASSAGE LTD
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:
1639294168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 UNITED WAY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERIC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54837-8938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-327-4322
Provider Business Mailing Address Fax Number:
715-327-8509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7818 MOLINE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEBSTER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54893-8545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-866-8301
Provider Business Practice Location Address Fax Number:
715-866-8374
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAURER
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BUSINESS OFFICE SUPERVISOR
Authorized Official Telephone Number:
715-327-4322

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  560014 , 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: 3181NO . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 43015300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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