Healthcare Provider Details

I. General information

NPI: 1871677419
Provider Name (Legal Business Name): BELLIN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 S MAIN ST
OCONTO FALLS WI
54154-1241
US

IV. Provider business mailing address

PO BOX 985
OCONTO FALLS WI
54154-0985
US

V. Phone/Fax

Practice location:
  • Phone: 920-846-3092
  • Fax: 920-846-8313
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number24066020
License Number StateWI

VIII. Authorized Official

Name: DIRENDIA SHACKELFORD
Title or Position: MANAGED CARE SPECIALIST
Credential:
Phone: 800-654-0889