Provider Demographics
NPI:1275574915
Name:CARDIOVASCULAR ASSOCIATES OF NORTHERN WISCONSIN, S.C.
Entity Type:Organization
Organization Name:CARDIOVASCULAR ASSOCIATES OF NORTHERN WISCONSIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2611
Mailing Address - Street 1:500 WIND RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401
Mailing Address - Country:US
Mailing Address - Phone:715-847-2611
Mailing Address - Fax:715-847-2465
Practice Address - Street 1:500 WIND RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-847-2611
Practice Address - Fax:715-847-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32756000Medicaid
WI61035Medicare ID - Type Unspecified
WI39180Medicare ID - Type Unspecified