Provider Demographics
NPI:1609844000
Name:PAIN CLINIC OF NORTHWESTERN WISCONSIN SC
Entity Type:Organization
Organization Name:PAIN CLINIC OF NORTHWESTERN WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MATHIAS
Authorized Official - Last Name:ENDRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-552-5346
Mailing Address - Street 1:PO BOX 1185
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1185
Mailing Address - Country:US
Mailing Address - Phone:715-552-5346
Mailing Address - Fax:715-838-6596
Practice Address - Street 1:1221 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5270
Practice Address - Country:US
Practice Address - Phone:715-552-5346
Practice Address - Fax:715-838-6596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32805000Medicaid
WI000020274Medicare ID - Type Unspecified