Healthcare Provider Details

I. General information

NPI: 1851390686
Provider Name (Legal Business Name): HEMOPHILIA OUTREACH OF WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/01/2022
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 BELLEVUE ST
GREEN BAY WI
54311-5622
US

IV. Provider business mailing address

2060 BELLEVUE ST
GREEN BAY WI
54311-5622
US

V. Phone/Fax

Practice location:
  • Phone: 920-965-0606
  • Fax: 920-965-0607
Mailing address:
  • Phone: 920-965-0606
  • Fax: 920-965-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number5123170
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number40681
License Number StateWI

VIII. Authorized Official

Name: MR. JAMISON BUXTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 920-965-0606