1871677419 NPI number — BELLIN MEDICAL GROUP

Table of content: KRISTEN JENNIFER MALONE BSN, RN, CCM (NPI 1366010001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871677419 NPI number — BELLIN MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLIN MEDICAL GROUP
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:
6
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:
1871677419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 985
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCONTO FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54154-0985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCONTO FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54154-1241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-846-3092
Provider Business Practice Location Address Fax Number:
920-846-8313
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHACKELFORD
Authorized Official First Name:
DIRENDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGED CARE SPECIALIST
Authorized Official Telephone Number:
800-654-0889

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  24066020 , 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: 5125427 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30611600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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