Healthcare Provider Details

I. General information

NPI: 1922340967
Provider Name (Legal Business Name): ADAM LEE HALVERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2013
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225000 HUMMINGBIRD RD STE 100
WAUSAU WI
54401-2950
US

IV. Provider business mailing address

225000 HUMMINGBIRD RD STE 100
WAUSAU WI
54401-2950
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number69905
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number34.012228
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number69905-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: