1356486369 NPI number — WAUSAU AVIATION MEDICINE SERVICES

Table of content: (NPI 1356486369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356486369 NPI number — WAUSAU AVIATION MEDICINE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAUSAU AVIATION MEDICINE SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1356486369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 477
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54402-0477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-675-5371
Provider Business Mailing Address Fax Number:
715-675-5381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 WOODS PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54403-7074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-675-5371
Provider Business Practice Location Address Fax Number:
715-675-5381
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURT
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
BRIGHAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
715-675-5371

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  27936 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21286900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201533595018 . This is a "ANTHEM BCBS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com