1134167083 NPI number — DR. SUSAN D GEDANKE MD

Table of content: DR. SUSAN D GEDANKE MD (NPI 1134167083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134167083 NPI number — DR. SUSAN D GEDANKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEDANKE
Provider First Name:
SUSAN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1134167083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10625 W NORTH AVE
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-2315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-877-5350
Provider Business Mailing Address Fax Number:
414-877-5360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3237 S 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215-4526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-527-8728
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

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: 207P00000X , with the licence number:  34512-020 , 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: 32167600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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