Basic Information
| Provider Information | |||||||||
| NPI: | 1740547702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREEN | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BREEN | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | BAKER | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | BELOIT HEALTH SYSTEM INC. | ||||||||
| Address2: | 1905 E. HUEBBE PARKWAY | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083645452 | ||||||||
| Practice Location | |||||||||
| Address1: | BELOIT MEMORIAL HOSPITAL | ||||||||
| Address2: | 1969 W. HART ROAD | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535112230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083635971 | ||||||||
| FaxNumber: | 6083635737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2012 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 207R00000X | E-9421 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 68342-20 | WI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 100073023 | 05 | WI | MEDICAID |