Provider Demographics
NPI:1407016686
Name:ADVANCED LIPIDOLOGY, S.C.
Entity Type:Organization
Organization Name:ADVANCED LIPIDOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-646-3223
Mailing Address - Street 1:524 MILWAUKEE ST
Mailing Address - Street 2:SUITE 180
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1460
Mailing Address - Country:US
Mailing Address - Phone:262-646-3223
Mailing Address - Fax:262-646-3443
Practice Address - Street 1:524 MILWAUKEE ST
Practice Address - Street 2:SUITE 180
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-1460
Practice Address - Country:US
Practice Address - Phone:262-646-3223
Practice Address - Fax:262-646-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32610400Medicaid