Provider Demographics
NPI:1356486369
Name:WAUSAU AVIATION MEDICINE SERVICES
Entity Type:Organization
Organization Name:WAUSAU AVIATION MEDICINE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:BRIGHAM
Authorized Official - Last Name:BURT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:715-675-5371
Mailing Address - Street 1:PO BOX 477
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-0477
Mailing Address - Country:US
Mailing Address - Phone:715-675-5371
Mailing Address - Fax:715-675-5381
Practice Address - Street 1:915 WOODS PLACE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-7074
Practice Address - Country:US
Practice Address - Phone:715-675-5371
Practice Address - Fax:715-675-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21286900Medicaid
WI201533595018OtherANTHEM BCBS
WIF35540Medicare UPIN
WI21286900Medicaid