Healthcare Provider Details

I. General information

NPI: 1679534697
Provider Name (Legal Business Name): WESTERN WISCONSIN MEDICAL ASSOCIATES HUDSON LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 STAGELINE ROAD
HUDSON WI
54016
US

IV. Provider business mailing address

403 STAGELINE ROAD
HUDSON WI
54016
US

V. Phone/Fax

Practice location:
  • Phone: 715-531-6800
  • Fax: 715-531-6801
Mailing address:
  • Phone: 715-531-6800
  • Fax: 715-531-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateWI

VIII. Authorized Official

Name: ERNIE WALLIN
Title or Position: ADMINISTRATOR DIRECTOR
Credential:
Phone: 715-531-6800