Healthcare Provider Details

I. General information

NPI: 1467561506
Provider Name (Legal Business Name): SPINE CENTER OF WISCONSIN SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY STE 355
MILWAUKEE WI
53215-3695
US

IV. Provider business mailing address

PO BOX 320695
FRANKLIN WI
53132
US

V. Phone/Fax

Practice location:
  • Phone: 414-235-3623
  • Fax: 414-235-3623
Mailing address:
  • Phone: 414-235-3623
  • Fax: 414-235-3623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number19042
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberXM39276
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY J BANACH
Title or Position: OFC MGR
Credential:
Phone: 414-235-3623