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General NPI Number Information
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NPI Number | 1316218167
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Entity Type | Organization
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Legal Business Name | PAIN CENTERS OF WISCONSIN - FORT ATKINSON, LLC
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Dates
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Enumeration Date | 01/25/2012
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Last Update Date | 10/07/2022
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Provider Practice Location Address
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Address Line | 1604 MADISON AVE
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City | FORT ATKINSON
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State | WI
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Zip | 53538-3101
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Country | US
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Telephone | 920-568-6596
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Fax | 920-568-9429
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Provider Business Mailing Address
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Address Line | PO BOX 660
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City | FORT ATKINSON
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State | WI
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Zip | 53538-0660
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Country | US
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Telephone | 920-568-9429
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Fax | 920-568-9429
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Authorized Official
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Title or Position | DIRECTOR/PRIVACY OFFICER
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Name | JOHN BARTELL
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Credential |
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Telephone | 920-568-6558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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