Healthcare Provider Details

I. General information

NPI: 1477900710
Provider Name (Legal Business Name): BJOSC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1767 PARK AVE STE 300
PLOVER WI
54467-4301
US

IV. Provider business mailing address

1767 PARK AVE STE 300
PLOVER WI
54467-4301
US

V. Phone/Fax

Practice location:
  • Phone: 715-359-6442
  • Fax: 715-393-0390
Mailing address:
  • Phone: 715-344-1260
  • Fax: 715-393-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN J HACKETT
Title or Position: PRESIDENT
Credential: MD
Phone: 715-393-0334