=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871677419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLIN MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 S MAIN ST
-----------------------------------------------------
City | OCONTO FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54154-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-846-3092
-----------------------------------------------------
Fax | 920-846-8313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 985
-----------------------------------------------------
City | OCONTO FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54154-0985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE SPECIALIST
-----------------------------------------------------
Name | DIRENDIA SHACKELFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-654-0889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | 24066020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------