MEDICARE: CH SPECIALTY SERVICES WI SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1063115319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CH SPECIALTY SERVICES WI SC

Provider Business Mailing Address
First Line	:	5750 JOHNSTON ST STE 205
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70503-5345
Country	:	US
Telephone Number	:	337-408-0797
Fax Number	:	337-943-0846

Provider Business Practice Location Address
First Line	:	1366 E SUMNER ST # 1002
Second Line	:
City	:	HARTFORD
State	:	WI
Zip	:	53027-1614
Country	:	US
Telephone Number	:	337-408-0797
Fax Number	:

Authorized Official
Title or Position	:	SR VP OF ADMINISTRATIVE SERVICES
Name	:	NICOLE HOWARD
Credential	:
Telephone Number	:	337-408-0797

Provider Enumeration Date	:	03/24/2023
Last Update Date	:	03/21/2025

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Directions to “CH SPECIALTY SERVICES WI SC ” Practice Location

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