=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013738509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINETIC SPINE AND PAIN SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2024
-----------------------------------------------------
Last Update Date | 11/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4491 N OAKLAND AVE
-----------------------------------------------------
City | SHOREWOOD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53211-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-999-3815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4491 N OAKLAND AVE
-----------------------------------------------------
City | SHOREWOOD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53211-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-999-3815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | OSCAR C WILLE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 414-232-7268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------