Basic Information
Provider Information | |||||||||
NPI: | 1568538189 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN WISCONSIN EMERGENCY ASSOCIATES SC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1446 N RANDALL AVE | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535451122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087587216 | ||||||||
FaxNumber: | 6087583216 | ||||||||
Practice Location | |||||||||
Address1: | 1969 W HART RD | ||||||||
Address2: |   | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535112230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087587217 | ||||||||
FaxNumber: | 6087583216 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2006 | ||||||||
LastUpdateDate: | 10/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAHER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6087587215 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D., FACEP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 32789100 | 05 | WI |   | MEDICAID |