=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700996576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILIP M MARDEN MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 SUMMIT AVENUE
-----------------------------------------------------
City | OCONOMOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53066-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-567-0366
-----------------------------------------------------
Fax | 262-567-0368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 SUMMIT AVENUE
-----------------------------------------------------
City | OCONOMOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53066-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-567-0366
-----------------------------------------------------
Fax | 262-567-0368
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PHILIP MANUEL MARDEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 262-667-0366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | 14664
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 14664
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 14664
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------