1730347519 NPI number — FOREFRONT DERMATOLOGY, S.C.

Table of content: (NPI 1730347519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730347519 NPI number — FOREFRONT DERMATOLOGY, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREFRONT DERMATOLOGY, S.C.
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:
1730347519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54220-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-683-5278
Provider Business Mailing Address Fax Number:
920-686-9674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 ROCKWOOD LN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-725-4100
Provider Business Practice Location Address Fax Number:
920-725-5528
Provider Enumeration Date:
05/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WERNLI
Authorized Official First Name:
BETSY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
920-482-0671

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NI0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000038200 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 21325200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1730347519 . This is a "NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 101710705 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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