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General NPI Number Information
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NPI Number | 1720574288
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Entity Type | Organization
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Legal Business Name | WISCONSIN PAIN MANAGEMENT SPECIALISTS, LLC
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Dates
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Enumeration Date | 07/09/2018
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Last Update Date | 07/24/2019
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Provider Practice Location Address
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Address Line | 1050 S. MILWAUKEE AVENUE SUITE 102
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City | BURLINGTON
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State | WI
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Zip | 53105
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Country | US
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Telephone | 262-758-6155
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 135
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City | HARTLAND
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State | WI
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Zip | 53029-0135
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. MICHAEL W JUNG
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Credential | MD
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Telephone | 262-412-6799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 53681-20
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License Number State | WI
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