Provider Demographics
NPI:1134150386
Name:CLUBB, MEREDITH CARTER (MD)
Entity type:Individual
Prefix:DR
First Name:MEREDITH
Middle Name:CARTER
Last Name:CLUBB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:STE 503
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-8213
Mailing Address - Fax:262-656-8233
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:STE 503
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-8213
Practice Address - Fax:262-656-8233
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI0021639208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30222000Medicare ID - Type Unspecified
WI0662280001Medicare NSC
WI000332413Medicare ID - Type Unspecified
WIB52124Medicare UPIN