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NPI Code Detail

MEDICARE: CORBY RAE STARK MA PC

MEDICARE: CORBY RAE STARK MA PC
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
1171M00000XCase Manager/Care Coordinator119 226WI

General Provider Information

NPI Number : 1780807149
Entity Type Code : Individual
Provider Name (Legal Business Name) : CORBY RAE STARK MA PC
Provider Business Mailing Address
First Line : 101 PERRY MOUND RD
Second Line :
City : BALSAM LAKE
State : WI
Zip : 54810-9001
Country : US
Telephone Number : 612-801-5854
Fax Number :
Provider Business Practice Location Address
First Line : 100 POLK COUNTY PLZ
Second Line : SUITE 50
City : BALSAM LAKE
State : WI
Zip : 54810-9071
Country : US
Telephone Number : 715-485-8842
Fax Number : 715-485-8490
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/11/2007
Last Update Date : 07/08/2007

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Directions to “ CORBY RAE STARK MA PC” Practice Location

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