Basic Information
Provider Information | |||||||||
NPI: | 1659699833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHORT | ||||||||
FirstName: | CHRISTY | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1836 SOUTH AVE | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 546015429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087827300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | N2950 STATE ROAD 67 | ||||||||
Address2: |   | ||||||||
City: | LAKE GENEVA | ||||||||
State: | WI | ||||||||
PostalCode: | 531472655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622450535 | ||||||||
FaxNumber: | 2622452248 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2010 | ||||||||
LastUpdateDate: | 07/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036138762 | IL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207P00000X | 60834-21 | WI | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1659699833 | 01 | WI | BCBSWI | OTHER | 1659699833 | 05 | WI |   | MEDICAID | 388608210 1 | 05 | IL |   | MEDICAID | SHORTCHR | 01 | WI | MERCYCARE INSURANCE | OTHER |