1699931519 NPI number — MR. DOUGLAS WILLIAM BENTHIEN M.S.

Table of content: MR. DOUGLAS WILLIAM BENTHIEN M.S. (NPI 1699931519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699931519 NPI number — MR. DOUGLAS WILLIAM BENTHIEN M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTHIEN
Provider First Name:
DOUGLAS
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
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:
1699931519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 SHUMAN BLVD
Provider Second Line Business Mailing Address:
STE 401
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60563-8123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-303-5380
Provider Business Mailing Address Fax Number:
630-303-5385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 N MAYFAIR RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-475-5809
Provider Business Practice Location Address Fax Number:
414-258-9429
Provider Enumeration Date:
07/30/2008

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: 237600000X , with the licence number:  311-156 , 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: 41146400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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