Provider Demographics
NPI:1053853960
Name:PINE GROVE FAMILY PRACTICE ASSOCIATES LTD
Entity Type:Organization
Organization Name:PINE GROVE FAMILY PRACTICE ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:715-834-2788
Mailing Address - Street 1:3221 STEIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4398
Mailing Address - Country:US
Mailing Address - Phone:715-834-2788
Mailing Address - Fax:715-858-3471
Practice Address - Street 1:3221 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4398
Practice Address - Country:US
Practice Address - Phone:715-834-2788
Practice Address - Fax:715-858-3471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000080256Medicare PIN