Healthcare Provider Details

I. General information

NPI: 1386604346
Provider Name (Legal Business Name): ALBERT JERVISS ALTER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 SEYBOLD RD STE 204
MADISON WI
53719-1362
US

IV. Provider business mailing address

W9107 STATE ROUTE 39
BLANCHARDVILLE WI
53516-9671
US

V. Phone/Fax

Practice location:
  • Phone: 608-271-7015
  • Fax: 608-271-7015
Mailing address:
  • Phone: 608-523-4506
  • Fax: 608-271-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number19772-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number19772-020
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19772
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number19772-020
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19772-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: