Healthcare Provider Details

I. General information

NPI: 1659547115
Provider Name (Legal Business Name): JAN MARIE WIRTH BC-HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAN MARIE FRANK BC-HIS

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 WASHINGTON ST
MANITOWOC WI
54220
US

IV. Provider business mailing address

2525 WASHINGTON ST.
MANITOWOC WI
54220
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-4990
  • Fax: 920-769-5131
Mailing address:
  • Phone: 920-682-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1169-060
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1169
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier42834600
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: