Healthcare Provider Details

I. General information

NPI: 1356586481
Provider Name (Legal Business Name): EDWARD WOLPERT MD SC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 W JEFFERSON
SPRING GREEN WI
53588
US

IV. Provider business mailing address

E7560 TROY VILLAGE RD.
SPRING GREEN WI
53588
US

V. Phone/Fax

Practice location:
  • Phone: 608-588-2600
  • Fax: 608-588-2644
Mailing address:
  • Phone: 608-588-2600
  • Fax: 608-588-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071002659
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number03637375
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18657020
License Number StateWI

VIII. Authorized Official

Name: DR. EDWARD A WOLPERT
Title or Position: PRESIDENT
Credential: MD PHD
Phone: 608-588-7173