MEDICARE: HEMOPHILIA OUTREACH OF WISCONSIN, INC.

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	332900000X	Non-Pharmacy Dispensing Site	5123170	WI
2	207RH0000X	Hematology (Internal Medicine) Physician	40681	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5123170	OTHER	WI	NCPDP NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851390686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEMOPHILIA OUTREACH OF WISCONSIN, INC.

Provider Business Mailing Address
First Line	:	2060 BELLEVUE ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5622
Country	:	US
Telephone Number	:	920-965-0606
Fax Number	:	920-965-0607

Provider Business Practice Location Address
First Line	:	2060 BELLEVUE ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5622
Country	:	US
Telephone Number	:	920-965-0606
Fax Number	:	920-965-0607

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JAMISON BUXTON
Credential	:
Telephone Number	:	920-965-0606

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	02/01/2022

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