Basic Information
| Provider Information | |||||||||
| NPI: | 1568523330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'ROURKE | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 NEBRASKA ST | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207467155 | ||||||||
| FaxNumber: | 9207462439 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 NEBRASKA ST | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207467155 | ||||||||
| FaxNumber: | 9207462439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 26694-20 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | OROURCOL-MO | 01 | WI | MERCYCARE INSURANCE | OTHER | 1568523330 | 01 | WI | DEANHEALTH PLAN | OTHER | 1568523330 | 01 | WI | BCBSWI | OTHER | 30669800 | 05 | WI | MEDICAID | 1568523330 | 05 | WI | MEDICAID |