Healthcare Provider Details

I. General information

NPI: 1992148183
Provider Name (Legal Business Name): MEDICAL ASSOCIATES OF NEILLSVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 E DIVISION ST
NEILLSVILLE WI
54456-2122
US

IV. Provider business mailing address

1105 E DIVISION ST
NEILLSVILLE WI
54456-2122
US

V. Phone/Fax

Practice location:
  • Phone: 715-819-1044
  • Fax: 715-819-1045
Mailing address:
  • Phone: 715-819-1044
  • Fax: 715-819-1045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49204
License Number StateWI

VIII. Authorized Official

Name: WENDY PROFFITT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 715-819-1044