Healthcare Provider Details

I. General information

NPI: 1720574288
Provider Name (Legal Business Name): WISCONSIN PAIN MANAGEMENT SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 S. MILWAUKEE AVENUE SUITE 102
BURLINGTON WI
53105
US

IV. Provider business mailing address

PO BOX 135
HARTLAND WI
53029-0135
US

V. Phone/Fax

Practice location:
  • Phone: 262-758-6155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number53681-20
License Number StateWI

VIII. Authorized Official

Name: DR. MICHAEL W JUNG
Title or Position: CEO
Credential: MD
Phone: 262-412-6799