Basic Information
| Provider Information | |||||||||
| NPI: | 1174621411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRIPP | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1446 N RANDALL AVE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087587215 | ||||||||
| FaxNumber: | 6087583216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1969 W HART RD | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087587218 | ||||||||
| FaxNumber: | 6087583216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 032160 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31811600 | 05 | WI | MEDICAID |