Basic Information
| Provider Information | |||||||||
| NPI: | 1801100243 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CSM COMMUNITY PHYSICIAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CSMCP CARDIAC RHYTHM SPECIALIST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78309 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142987280 | ||||||||
| FaxNumber: | 4142987281 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N LAKE DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142987280 | ||||||||
| FaxNumber: | 4142987281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BJORN | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4142987284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA ST MARYS HOSPITAL MILWAUKEE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 32793800 | 05 | WI | MEDICAID |