Healthcare Provider Details

I. General information

NPI: 1326376609
Provider Name (Legal Business Name): GREGORY E GINTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BROADWAY ST
BARABOO WI
53913-2183
US

IV. Provider business mailing address

PO BOX 29
BARABOO WI
53913-0029
US

V. Phone/Fax

Practice location:
  • Phone: 608-355-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number127341121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: