Provider Demographics
NPI:1316218167
Name:PAIN CENTERS OF WISCONSIN - FORT ATKINSON, LLC
Entity Type:Organization
Organization Name:PAIN CENTERS OF WISCONSIN - FORT ATKINSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-568-6558
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0660
Mailing Address - Country:US
Mailing Address - Phone:920-568-9429
Mailing Address - Fax:920-568-9429
Practice Address - Street 1:1604 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3101
Practice Address - Country:US
Practice Address - Phone:920-568-6596
Practice Address - Fax:920-568-9429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100176317Medicaid