Basic Information
Provider Information | |||||||||
NPI: | 1932302130 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRIERE | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | CAMILLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CAVALLARO | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | CAMILLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2895 OSMUNDSEN RD | ||||||||
Address2: |   | ||||||||
City: | FITCHBURG | ||||||||
State: | WI | ||||||||
PostalCode: | 537115160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047918759 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1945 LAKEPOINTE DR | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750576469 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008352362 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2007 | ||||||||
LastUpdateDate: | 09/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 060809 | GA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.