1982064366 NPI number — MADISON NEUROPSYCHOLOGICAL SERVICES LLC

Table of content: (NPI 1982064366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982064366 NPI number — MADISON NEUROPSYCHOLOGICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON NEUROPSYCHOLOGICAL SERVICES LLC
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:
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:
1982064366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6510 GRAND TETON PLZ STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53719-1031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-841-1606
Provider Business Mailing Address Fax Number:
608-492-2573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6510 GRAND TETON PLZ STE 102
Provider Second Line Business Practice Location Address:
STE 24
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-841-1606
Provider Business Practice Location Address Fax Number:
608-492-2573
Provider Enumeration Date:
02/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PORTER
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
608-841-1606

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  3198-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 3198-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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