Provider Demographics
NPI:1124004445
Name:SEVERE, REBECCA S
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:S
Last Name:SEVERE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:SUDENBAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2338
Mailing Address - Fax:414-385-8987
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-6000
Practice Address - Fax:414-649-5296
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40372207R00000X
TNMD40372208000000X
WI45223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3283015Medicaid
TN33364651Medicaid
TN3336466Medicaid
TN4116218OtherBCBS
4152683OtherBCBST
TN3732438Medicaid
4152683OtherBCBST
TNI48235Medicare UPIN
TN33364651Medicaid
TN3336466Medicare PIN
3283015Medicare PIN