1902864309 NPI number — MRS. COLLEEN PATRICIA ROURKE M.S.

Table of content: MRS. COLLEEN PATRICIA ROURKE M.S. (NPI 1902864309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902864309 NPI number — MRS. COLLEEN PATRICIA ROURKE M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROURKE
Provider First Name:
COLLEEN
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REED
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902864309
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:
1852 N 69TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53213-2316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-453-0303
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12970 W BLUEMOUND RD
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
ELM GROVE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53122-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-780-1020
Provider Business Practice Location Address Fax Number:
262-780-1022
Provider Enumeration Date:
05/03/2006

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: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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