Basic Information
Provider Information | |||||||||
NPI: | 1851414601 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEAN RETAIL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SSM HEALTH DAVIS DUEHR DEAN EYE CARE - N. HIGH POINT ROAD, MADISON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1808 W BELTLINE HWY | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537132334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082946218 | ||||||||
FaxNumber: | 6082501384 | ||||||||
Practice Location | |||||||||
Address1: | 752 N HIGH POINT RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537172236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088244000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2007 | ||||||||
LastUpdateDate: | 08/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRINNELL | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT-FINANCE | ||||||||
AuthorizedOfficialTelephone: | 6082603586 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   | WI | N |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   | 156FX1800X |   | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
ID | Type | State | Issuer | Description | 384-43-700 | 05 | WI |   | MEDICAID |