Healthcare Provider Details

I. General information

NPI: 1497810857
Provider Name (Legal Business Name): COMPREHENSIVE PAIN MANAGEMENT OF THE FOX VALLEY, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GRANT ST SUITE 335
APPLETON WI
54911-3490
US

IV. Provider business mailing address

100 THEDA CLARK MEDICAL PLZ SUITE 252
NEENAH WI
54956-2763
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-7230
  • Fax:
Mailing address:
  • Phone: 920-733-7230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number36140-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number36140-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number36140-20
License Number StateWI

VIII. Authorized Official

Name: ALEXANDER E YAKOVLEV
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 920-733-7230