Basic Information
Provider Information | |||||||||
NPI: | 1366773780 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CSM COMMUNITY PHYSICIAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CSMCP CARDIAC RHYTHM SPECIALIST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 78309 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532780001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142987280 | ||||||||
FaxNumber: | 4142987281 | ||||||||
Practice Location | |||||||||
Address1: | 2700 W 9TH AVE | ||||||||
Address2: | SUITE 106 | ||||||||
City: | OSHKOSH | ||||||||
State: | WI | ||||||||
PostalCode: | 549047247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142987280 | ||||||||
FaxNumber: | 4142987281 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2010 | ||||||||
LastUpdateDate: | 11/24/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BJORN | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4142987284 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COLUMBIA ST MARYS HOSPITAL MILWAUKEE INC | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 363AM0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LA2100X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 261QM2500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
ID | Type | State | Issuer | Description | 32793800 | 05 | WI |   | MEDICAID |