1730236977 NPI number — PHYLLIS TERRY EISENBERG II BS RN, MEED

Table of content: PHYLLIS TERRY EISENBERG II BS RN, MEED (NPI 1730236977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730236977 NPI number — PHYLLIS TERRY EISENBERG II BS RN, MEED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISENBERG
Provider First Name:
PHYLLIS
Provider Middle Name:
TERRY
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
BS RN, MEED
Provider Gender Code:
F

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:
1730236977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 170911
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53217-8081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-795-4104
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N SUNNY SLOPE RD
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-754-9460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

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: 101YP2500X , with the licence number:  1884-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WP0807X , with the licence number: 51189-030 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 39790000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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