Basic Information
Provider Information | |||||||||
NPI: | 1063447423 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARRIGAN | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3006 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 54303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204991428 | ||||||||
FaxNumber: | 9204995808 | ||||||||
Practice Location | |||||||||
Address1: | 1789 SHAWANO AVE | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 54303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204991428 | ||||||||
FaxNumber: | 9204995808 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 11/05/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20858-020 | WI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 14115 | 01 |   | DEAN HEALTH | OTHER | 1018425003 | 01 |   | UNITED HEALTHCARE AMERICH | OTHER | 30153800 | 05 | WI |   | MEDICAID | P00028700 | 01 |   | RR MEDICARE | OTHER | 1018425002 | 01 |   | UNITED HEALTHCARE AMERICH | OTHER | 1997693 | 05 | MI |   | MEDICAID | 300020916 | 01 |   | RR MEDICARE | OTHER | 567565 | 01 |   | DEAN HEALTH | OTHER |