Provider Demographics
NPI:1992998884
Name:TARA L. PASSOW MD INC
Entity type:Organization
Organization Name:TARA L. PASSOW MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PASSOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-885-2622
Mailing Address - Street 1:700 HILLCREST CT
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2418
Mailing Address - Country:US
Mailing Address - Phone:920-885-2622
Mailing Address - Fax:920-885-4419
Practice Address - Street 1:700 HILLCREST CT
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2418
Practice Address - Country:US
Practice Address - Phone:920-885-2622
Practice Address - Fax:920-885-4419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24736174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty