Healthcare Provider Details

I. General information

NPI: 1316409196
Provider Name (Legal Business Name): JACK M MASSEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 04/01/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 14TH ST
BARABOO WI
53913-1539
US

IV. Provider business mailing address

1808 W BETLINE HWY
MADISON WI
53713-2334
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-1400
  • Fax: 608-355-7007
Mailing address:
  • Phone: 608-280-4647
  • Fax: 608-250-1384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number75006-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: