Provider Demographics
NPI:1629091566
Name:CUMBERLAND CLINIC SC
Entity Type:Organization
Organization Name:CUMBERLAND CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-822-2231
Mailing Address - Street 1:1475 WEBB ST
Mailing Address - Street 2:PO BOX 127
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829
Mailing Address - Country:US
Mailing Address - Phone:715-822-2231
Mailing Address - Fax:715-822-2023
Practice Address - Street 1:1475 WEBB ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829
Practice Address - Country:US
Practice Address - Phone:715-822-2231
Practice Address - Fax:715-822-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32742200Medicaid
05002Medicare ID - Type Unspecified