Healthcare Provider Details

I. General information

NPI: 1316218167
Provider Name (Legal Business Name): PAIN CENTERS OF WISCONSIN - FORT ATKINSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 MADISON AVE
FORT ATKINSON WI
53538-3101
US

IV. Provider business mailing address

PO BOX 660
FORT ATKINSON WI
53538-0660
US

V. Phone/Fax

Practice location:
  • Phone: 920-568-6596
  • Fax: 920-568-9429
Mailing address:
  • Phone: 920-568-9429
  • Fax: 920-568-9429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN BARTELL
Title or Position: DIRECTOR/PRIVACY OFFICER
Credential:
Phone: 920-568-6558