Healthcare Provider Details

I. General information

NPI: 1174531123
Provider Name (Legal Business Name): PREVENTIVE CARDIOLOGY OF CENTRAL WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 WESTON AVE
WESTON WI
54476
US

IV. Provider business mailing address

BOX 2003
WAUSAU WI
54402-2003
US

V. Phone/Fax

Practice location:
  • Phone: 715-370-5433
  • Fax: 715-359-3485
Mailing address:
  • Phone: 715-370-5433
  • Fax: 715-359-3485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22225020020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number22225020020
License Number StateWI

VIII. Authorized Official

Name: EARL S PERRIGO
Title or Position: PRESIDENT
Credential: MD
Phone: 715-370-5433