=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962438614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISCONSIN UPPER PENINSULA ONCOLOGY MANAGEMENT SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 07/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 SHORE DR
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-4242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-735-6523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 SHORE DR ST. VINCENT HOSPITAL
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-4242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-735-6523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DAN CARLSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-735-8016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------