=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649141060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERVENTIONAL PAIN SPECIALISTS OF WISCONSIN, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2025
-----------------------------------------------------
Last Update Date | 09/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 CENEX DR UNIT J
-----------------------------------------------------
City | RICE LAKE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54868-1892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-234-7246
-----------------------------------------------------
Fax | 715-234-7242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 CENEX DR UNIT J
-----------------------------------------------------
City | RICE LAKE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54868-1892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-234-7246
-----------------------------------------------------
Fax | 715-234-7242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW THORSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 715-234-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------