1992800791 NPI number — INTERVENTIONAL PAIN SPECIALISTS OF WISCONSIN, SC

Table of content: (NPI 1992800791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992800791 NPI number — INTERVENTIONAL PAIN SPECIALISTS OF WISCONSIN, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN SPECIALISTS OF WISCONSIN, 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:
1992800791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 CENEX DR UNIT J
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICE LAKE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54868-1892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-234-7246
Provider Business Mailing Address Fax Number:
715-234-7242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 CENEX DR UNIT J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICE LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54868-1892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-234-7246
Provider Business Practice Location Address Fax Number:
715-234-7242
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRENDEL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
715-234-7246

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  34036 , 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: 31913700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 397524621000 . This is a "BLUE CROSS WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 34036 . This is a "WI LICENSE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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