1972601524 NPI number — SUSAN J WATKINS OTR

Table of content: SUSAN J WATKINS OTR (NPI 1972601524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972601524 NPI number — SUSAN J WATKINS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATKINS
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1972601524
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:
700 WEST AVE S
Provider Second Line Business Mailing Address:
PHYSICIAN SERVICES
Provider Business Mailing Address City Name:
LA CROSSE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54601-4783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-791-4156
Provider Business Mailing Address Fax Number:
608-791-9898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 WEST AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
56401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-791-9768
Provider Business Practice Location Address Fax Number:
608-791-7124
Provider Enumeration Date:
09/20/2006

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: 225X00000X , with the licence number:  1789 , 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: 40753900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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