1962533455 NPI number — CMH PRIMARY CARE CLINIC MOUTAIN-PHYSICIAN DISPENSARY

Table of content: (NPI 1962533455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962533455 NPI number — CMH PRIMARY CARE CLINIC MOUTAIN-PHYSICIAN DISPENSARY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CMH PRIMARY CARE CLINIC MOUTAIN-PHYSICIAN DISPENSARY
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:
1962533455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14353 HWY 32 & 64
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-276-1600
Provider Business Mailing Address Fax Number:
715-276-1800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14353 HWY 32 & 64
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-276-1600
Provider Business Practice Location Address Fax Number:
715-276-1800
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREMBAN
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICIAN DISPENSARY
Authorized Official Telephone Number:
715-276-1600

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  23967-020 , 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: 5128904 . This is a "NCPDP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 395585708005 . This is a "GREMBAN BC" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 31756500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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