Provider Demographics
NPI:1467561506
Name:SPINE CENTER OF WISCONSIN SC
Entity Type:Organization
Organization Name:SPINE CENTER OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFC MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-235-3623
Mailing Address - Street 1:PO BOX 320695
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132
Mailing Address - Country:US
Mailing Address - Phone:414-235-3623
Mailing Address - Fax:414-235-3623
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 355
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3695
Practice Address - Country:US
Practice Address - Phone:414-235-3623
Practice Address - Fax:414-235-3623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19042261QM2500X
WIXM39276261QR0200X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30876700Medicaid
WIB52378Medicare UPIN
WI30876700Medicaid
WI000002610Medicare PIN