Provider Demographics
NPI:1184746828
Name:UNIVERSITY OF WISCONSIN SYSTEM NON PAYROLL
Entity type:Organization
Organization Name:UNIVERSITY OF WISCONSIN SYSTEM NON PAYROLL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-263-4938
Mailing Address - Street 1:122 E OLIN AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1468
Mailing Address - Country:US
Mailing Address - Phone:608-265-9438
Mailing Address - Fax:608-263-4681
Practice Address - Street 1:122 E OLIN AVE STE 255
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713
Practice Address - Country:US
Practice Address - Phone:608-265-9438
Practice Address - Fax:608-263-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21252100Medicaid
WI15321Medicare ID - Type Unspecified