Healthcare Provider Details

I. General information

NPI: 1255974952
Provider Name (Legal Business Name): INTEGRATIVE HEALTH CENTER OF CENTRAL WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 E WASHINGTON AVE STE A
MADISON WI
53704-4332
US

IV. Provider business mailing address

3205 E WASHINGTON AVE STE A
MADISON WI
53704-4332
US

V. Phone/Fax

Practice location:
  • Phone: 608-222-2700
  • Fax: 608-222-2771
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN COTTER
Title or Position: OWNER
Credential: MD
Phone: 608-222-2700