Provider Demographics
NPI:1174728471
Name:VILLAGE OF SHOREWOOD HEALTH DEPARTMENT
Entity type:Organization
Organization Name:VILLAGE OF SHOREWOOD HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TOMASELLO
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:414-847-2710
Mailing Address - Street 1:3930 N MURRAY AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2303
Mailing Address - Country:US
Mailing Address - Phone:414-847-2710
Mailing Address - Fax:414-847-2714
Practice Address - Street 1:2010 E SHOREWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2557
Practice Address - Country:US
Practice Address - Phone:414-847-2710
Practice Address - Fax:414-847-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55133-030251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI82410Medicare ID - Type UnspecifiedPROVIDER NUMBER