=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104005685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOINT SCHOOL DISTRICT NO 2 CO CITY & TOWN OF BRILLION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2007
-----------------------------------------------------
Last Update Date | 07/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 S MAIN STREET
-----------------------------------------------------
City | BRILLION
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54110-1294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-756-2368
-----------------------------------------------------
Fax | 920-756-3705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 S MAIN STREET
-----------------------------------------------------
City | BRILLION
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54110-1294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-756-2368
-----------------------------------------------------
Fax | 920-756-3705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DISTRICT ADMINISTRATOR
-----------------------------------------------------
Name | DR. DOMINICK MADISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-756-2368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------