MEDICARE: WISCONSIN PAIN MANAGEMENT, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician
2	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1093052243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN PAIN MANAGEMENT, S.C.

Provider Business Mailing Address
First Line	:	225 S EXECUTIVE DR
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-4257
Country	:	US
Telephone Number	:	262-787-4050
Fax Number	:	262-782-6040

Provider Business Practice Location Address
First Line	:	1050 MILWAUKEE AVE
Second Line	:	SUITE 102
City	:	BURLINGTON
State	:	WI
Zip	:	53105-1362
Country	:	US
Telephone Number	:	262-763-8000
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DR. ANTHONY G CONRARDY
Credential	:	M.D.
Telephone Number	:	262-763-8000

Provider Enumeration Date	:	01/08/2013
Last Update Date	:	01/08/2013

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