Basic Information
| Provider Information | |||||||||
| NPI: | 1518904762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REGAN | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | CSMCP CLINIC CREDENTIALING | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143262218 | ||||||||
| FaxNumber: | 4143262208 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 N TAYLOR DRIVE | ||||||||
| Address2: | COLUMBIA ST MARY'S SHEYBOYGAN OUTPATIENT CENTER | ||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530813090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622432500 | ||||||||
| FaxNumber: | 2622435395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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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 | 207RG0100X | 20082 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1518904762 | 05 | WI | MEDICAID |