Provider Demographics
NPI:1568821841
Name:WISCONSIN TELE-MED NETWORK
Entity Type:Organization
Organization Name:WISCONSIN TELE-MED NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-416-3801
Mailing Address - Street 1:W146S6974 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-3116
Mailing Address - Country:US
Mailing Address - Phone:414-416-3801
Mailing Address - Fax:
Practice Address - Street 1:6923 39TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7129
Practice Address - Country:US
Practice Address - Phone:414-416-3801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty