Basic Information
| Provider Information | |||||||||
| NPI: | 1750400735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARQUETTE UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARQUETTE NEIGHBORHOOD HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1452 N 7TH ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532052301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149339100 | ||||||||
| FaxNumber: | 4149339200 | ||||||||
| Practice Location | |||||||||
| Address1: | 1452 N 7TH ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532052301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149339100 | ||||||||
| FaxNumber: | 4149339200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALLAHAN | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEAN | ||||||||
| AuthorizedOfficialTelephone: | 4142883812 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 43961000 | 05 | WI | MEDICAID |