1760540405 NPI number — MR. RONALD JOHN GAMMON CADCIII CCS

Table of content: MR. RONALD JOHN GAMMON CADCIII CCS (NPI 1760540405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760540405 NPI number — MR. RONALD JOHN GAMMON CADCIII CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMMON
Provider First Name:
RONALD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CADCIII CCS
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:
1760540405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NORTH SHORE CENTER
Provider Second Line Business Mailing Address:
10303 N PORT WASHINGTON RD SQ 203
Provider Business Mailing Address City Name:
MEGUON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-241-5955
Provider Business Mailing Address Fax Number:
262-241-5926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NORTH SHORE CENTER
Provider Second Line Business Practice Location Address:
10303 N PORT WASHINGTON RD SQ 203
Provider Business Practice Location Address City Name:
MEGUON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-241-5955
Provider Business Practice Location Address Fax Number:
262-241-5926
Provider Enumeration Date:
12/05/2006

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: 101YA0400X , with the licence number:  2136 , 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)





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