Provider Demographics
NPI:1013006816
Name:CENTRAL WISCONSIN ANESTHESI
Entity Type:Organization
Organization Name:CENTRAL WISCONSIN ANESTHESI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-361-5538
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5538
Mailing Address - Fax:920-361-5499
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5538
Practice Address - Fax:920-361-5499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000021415OtherMEDICARE
WI000026095OtherMEDICARE
WI43419700Medicaid
R40168Medicare UPIN
R79414Medicare UPIN
WI43419700Medicaid
R40513Medicare UPIN
WI000026095OtherMEDICARE
S26146Medicare UPIN
S36296Medicare UPIN