MEDICARE: STATELINE ANESTHESIOLOGISTS 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	207L00000X	Anesthesiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	541844	OTHER	WI	DEANCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316937519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATELINE ANESTHESIOLOGISTS SC

Provider Business Mailing Address
First Line	:	PO BOX 686
Second Line	:
City	:	BELOIT
State	:	WI
Zip	:	53512-0686
Country	:	US
Telephone Number	:	608-362-7444
Fax Number	:	608-362-0417

Provider Business Practice Location Address
First Line	:	1969 W HART RD
Second Line	:	BELOIT MEMORIAL HOSPITAL
City	:	BELOIT
State	:	WI
Zip	:	53511-2230
Country	:	US
Telephone Number	:	608-364-5355
Fax Number	:	608-362-0417

Authorized Official
Title or Position	:	PRESIDENT OF CORPORATION
Name	:	DR. JIMSON C TSE
Credential	:	MD
Telephone Number	:	608-362-7444

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	06/25/2014

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