Provider Demographics
NPI:1497081863
Name:NOVA WOUND CARE SC
Entity Type:Organization
Organization Name:NOVA WOUND CARE SC
Other - Org Name:NOVA WOUND CARE SC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPACZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-559-9015
Mailing Address - Street 1:5801 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4057
Mailing Address - Country:US
Mailing Address - Phone:262-788-6102
Mailing Address - Fax:262-788-6103
Practice Address - Street 1:1420 RENAISSANCE DR STE 201
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1330
Practice Address - Country:US
Practice Address - Phone:847-559-9015
Practice Address - Fax:847-574-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.619557208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100088299Medicaid
IL036.092302Medicaid
IL1871689208Medicaid