Basic Information
Provider Information | |||||||||
NPI: | 1053637439 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LINCOLN | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | HASTINGS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OGREN | ||||||||
OtherFirstName: | ANNE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4425 N PORT WASHINGTON RD | ||||||||
Address2: | CLINIC CREDENTIALING | ||||||||
City: | GLENDALE | ||||||||
State: | WI | ||||||||
PostalCode: | 532121082 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4143262218 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | N143W6515 PIONEER RD | ||||||||
Address2: |   | ||||||||
City: | CEDARBURG | ||||||||
State: | WI | ||||||||
PostalCode: | 530122705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2623776933 | ||||||||
FaxNumber: | 2623762495 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2010 | ||||||||
LastUpdateDate: | 10/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 56585 | WI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1053637439 | 05 | WI |   | MEDICAID |