1700309101 NPI number — WISCONSIN INTERVENTIONAL PAIN SOLUTIONS SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700309101 NPI number — WISCONSIN INTERVENTIONAL PAIN SOLUTIONS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISCONSIN INTERVENTIONAL PAIN SOLUTIONS SC
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:
1700309101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6163 WASHINGTON CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53213-2471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-800-5359
Provider Business Mailing Address Fax Number:
414-800-6308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 N MAYFAIR RD STE 325
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-1443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-800-5359
Provider Business Practice Location Address Fax Number:
414-800-6308
Provider Enumeration Date:
07/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HOFSCHULZ
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
414-800-5359

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , 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: 1992789390 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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