MEDICARE: PAI PARTICIPANT 23 SC

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1528674801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAI PARTICIPANT 23 SC

Provider Business Mailing Address
First Line	:	PO BOX 639676
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-9676
Country	:	US
Telephone Number	:	859-291-4800
Fax Number	:	859-655-8588

Provider Business Practice Location Address
First Line	:	1475 BIRCH HILL LN
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166-3707
Country	:	US
Telephone Number	:	715-526-3161
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ERIN LAIRD
Credential	:
Telephone Number	:	410-458-8713

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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