Basic Information
Provider Information | |||||||||
NPI: | 1346266319 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF WISCONSIN SYSTEM NON PAYROLL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UW SYSTEMS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7974 UW HEALTH COURT | ||||||||
Address2: |   | ||||||||
City: | MIDDLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 535625531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088295485 | ||||||||
FaxNumber: | 6088330999 | ||||||||
Practice Location | |||||||||
Address1: | 750 HIGHLAND AVE FL 4 | ||||||||
Address2: | HEALTH SCIENCES LEARNING CENTER | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537052221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082634938 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 06/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOUNT | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR ASSOCIATE DEAN OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 6082634938 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 32855400 | 05 | WI |   | MEDICAID |