Healthcare Provider Details

I. General information

NPI: 1104197243
Provider Name (Legal Business Name): KEVIN BJORK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

V. Phone/Fax

Practice location:
  • Phone: 608-256-1901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4753-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: