Basic Information
| Provider Information | |||||||||
| NPI: | 1821021429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTBUCH | ||||||||
| FirstName: | ARTHUR | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 849 KELLOGG AVE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087557960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 849 KELLOGG AVE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087557960 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41950 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 41950 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS0010X | 41950 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 30494 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 30493 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS0010X | 30494 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32631600 | 05 | WI | MEDICAID | AA7657793 | 01 | DEA | OTHER |