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General NPI Number Information
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NPI Number | 1366785610
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Entity Type | Organization
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Legal Business Name | GREATER MILWAUKEE PAIN CLINIC LTD
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Dates
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Enumeration Date | 04/04/2013
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Last Update Date | 04/04/2013
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Provider Practice Location Address
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Address Line | 10817 W LINCOLN AVE
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City | WEST ALLIS
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State | WI
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Zip | 53227-1127
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Country | US
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Telephone | 414-327-6767
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Fax |
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Provider Business Mailing Address
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Address Line | 10817 W LINCOLN AVE
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City | WEST ALLIS
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State | WI
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Zip | 53227-1127
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Country | US
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Telephone | 414-327-6767
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TIMOTHY ALLAN KOSTUSAK
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Credential | D.C.
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Telephone | 414-327-6767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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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 | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #4
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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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