Provider Demographics
NPI:1295837425
Name:MARK P HASTINGS, DPM, SC
Entity Type:Organization
Organization Name:MARK P HASTINGS, DPM, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:414-873-0772
Mailing Address - Street 1:N86W16462 JACOBSON DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2833
Mailing Address - Country:US
Mailing Address - Phone:262-255-1040
Mailing Address - Fax:262-255-4090
Practice Address - Street 1:3431 N 51ST BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3228
Practice Address - Country:US
Practice Address - Phone:262-255-1040
Practice Address - Fax:262-255-4090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43214100Medicaid
WI41722300Medicaid
WI4248430001OtherMEDICARE DME
WI000086672Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
WI43214100Medicaid
WI000086663Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
WI000086663 - ALL OTHEMedicare PIN
WI000086672-MILW COUNTMedicare PIN