Provider Demographics
NPI:1568456218
Name:PODIATRY ASSOCIATES OF WAUSAU, S.C.
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES OF WAUSAU, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOURDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:715-675-2321
Mailing Address - Street 1:1445 MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2646
Mailing Address - Country:US
Mailing Address - Phone:715-675-2321
Mailing Address - Fax:715-675-6530
Practice Address - Street 1:1445 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2646
Practice Address - Country:US
Practice Address - Phone:715-675-2321
Practice Address - Fax:715-675-6530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0427710001Medicare NSC
WI82903Medicare PIN
WICS6623Medicare PIN