Healthcare Provider Details

I. General information

NPI: 1013006816
Provider Name (Legal Business Name): CENTRAL WISCONSIN ANESTHESI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

IV. Provider business mailing address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5538
  • Fax: 920-361-5499
Mailing address:
  • Phone: 920-361-5538
  • Fax: 920-361-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN J DOMKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 920-361-5538