Provider Demographics
NPI:1669565347
Name:BARRY M ALTENBERG MD SC
Entity type:Organization
Organization Name:BARRY M ALTENBERG MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-898-7100
Mailing Address - Street 1:1055 PRAIRIE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406
Mailing Address - Country:US
Mailing Address - Phone:262-898-7100
Mailing Address - Fax:262-898-7171
Practice Address - Street 1:5802 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-886-5700
Practice Address - Fax:262-886-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI15872261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31175300Medicaid
WI32891300Medicaid
WIB51157Medicare UPIN
WI31175300Medicaid