Provider Demographics
NPI:1770846776
Name:COMPREHENSIVE PAIN MANAGEMENT OF THE FOX VALLEY, S.C.
Entity Type:Organization
Organization Name:COMPREHENSIVE PAIN MANAGEMENT OF THE FOX VALLEY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:E
Authorized Official - Last Name:YAKOVLEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-733-7230
Mailing Address - Street 1:100 THEDA CLARK MEDICAL PLZ
Mailing Address - Street 2:SUITE 252
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2763
Mailing Address - Country:US
Mailing Address - Phone:920-733-7230
Mailing Address - Fax:920-729-0347
Practice Address - Street 1:100 THEDA CLARK MEDICAL PLZ
Practice Address - Street 2:SUITE 252
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2763
Practice Address - Country:US
Practice Address - Phone:920-733-7230
Practice Address - Fax:920-729-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36140-20207LP2900X, 208VP0014X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34086400Medicaid
WI6687320001Medicare NSC
WI34086400Medicaid