Provider Demographics
NPI:1659524981
Name:DEREK J CRIPPS LLC
Entity Type:Organization
Organization Name:DEREK J CRIPPS LLC
Other - Org Name:DEREK J CRIPPS MD LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:EMERITUS PROFESSOR OF MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CRIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-244-1712
Mailing Address - Street 1:727 WILDER DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-6011
Mailing Address - Country:US
Mailing Address - Phone:608-244-1712
Mailing Address - Fax:608-244-4338
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-5093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15388261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB52234Medicare UPIN