Basic Information
Provider Information | |||||||||
NPI: | 1790954063 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TALERICO | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | VERONICA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 752 N HIGH POINT RD | ||||||||
Address2: | DEAN CLINIC | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537172236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088244000 | ||||||||
FaxNumber: | 6088244910 | ||||||||
Practice Location | |||||||||
Address1: | 752 N HIGH POINT RD | ||||||||
Address2: | DEAN CLINIC | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537172236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088244000 | ||||||||
FaxNumber: | 6088244910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2008 | ||||||||
LastUpdateDate: | 02/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 52891-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 61081 | 01 | WI | DEAN HEALTH INSURANCE | OTHER |