Basic Information
| Provider Information | |||||||||
| NPI: | 1790152130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERWOERD | ||||||||
| FirstName: | CARMEN | ||||||||
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| OtherLastName: | GRIEGO | ||||||||
| OtherFirstName: | CARMEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2639 UNIVERSITY AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537053750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082630572 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2639 UNIVERSITY AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537053750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082630572 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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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 | 2080N0001X | 66834 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.