1306828298 NPI number — GEORGE P WUENSCH PAC

Table of content: GEORGE P WUENSCH PAC (NPI 1306828298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306828298 NPI number — GEORGE P WUENSCH PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WUENSCH
Provider First Name:
GEORGE
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306828298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRON MOUNTAIN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49801-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-774-1313
Provider Business Mailing Address Fax Number:
906-776-5639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 S STEPHENSON AVE STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRON MOUNTAIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49801-3649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-776-5800
Provider Business Practice Location Address Fax Number:
906-228-0200
Provider Enumeration Date:
11/16/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1204023 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601003229 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00297697 . This is a "RR MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 0852210320 . This is a "BCBS MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 42868400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".