Provider Demographics
NPI:1679735997
Name:DIABETES OSTEOPOROSIS THYROID ENDOCRINE CENTER, LLC
Entity type:Organization
Organization Name:DIABETES OSTEOPOROSIS THYROID ENDOCRINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-619-3473
Mailing Address - Street 1:4077 LIGHTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3113
Mailing Address - Country:US
Mailing Address - Phone:262-619-3473
Mailing Address - Fax:262-619-9600
Practice Address - Street 1:1532 S GREEN BAY RD STE 300
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4410
Practice Address - Country:US
Practice Address - Phone:262-619-3473
Practice Address - Fax:262-619-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41940020207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000052024Medicare PIN