=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659568657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN E. BOZELKA, MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2007
-----------------------------------------------------
Last Update Date | 10/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 UNIVERSITY DR
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-732-4181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 UNIVERSITY DR
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-732-4181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIAN E BOZELKA
-----------------------------------------------------
Credential | MD PHD
-----------------------------------------------------
Telephone | 715-732-4181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------