1942712344 NPI number — DIVINE SAVIOR HEALTHCARE, INC.

Table of content: MICHAEL MOREAU PA (NPI 1366472847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942712344 NPI number — DIVINE SAVIOR HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE SAVIOR HEALTHCARE, INC.
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:
1942712344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29980 NETWORK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-1299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-847-2304
Provider Business Mailing Address Fax Number:
715-843-1188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N4390 CROSSROADS CLINIC ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-589-5333
Provider Business Practice Location Address Fax Number:
608-742-6098
Provider Enumeration Date:
10/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
YANG
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SVP & CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
715-847-2526

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , 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: 32767300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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