Healthcare Provider Details

I. General information

NPI: 1366785610
Provider Name (Legal Business Name): GREATER MILWAUKEE PAIN CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10817 W LINCOLN AVE
WEST ALLIS WI
53227-1127
US

IV. Provider business mailing address

10817 W LINCOLN AVE
WEST ALLIS WI
53227-1127
US

V. Phone/Fax

Practice location:
  • Phone: 414-327-6767
  • Fax:
Mailing address:
  • Phone: 414-327-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY ALLAN KOSTUSAK
Title or Position: PRESIDENT
Credential: D.C.
Phone: 414-327-6767