Provider Demographics
NPI:1851390686
Name:HEMOPHILIA OUTREACH OF WISCONSIN, INC.
Entity Type:Organization
Organization Name:HEMOPHILIA OUTREACH OF WISCONSIN, INC.
Other - Org Name:HEMOPHILIA OUTREACH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BUXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-965-0606
Mailing Address - Street 1:2060 BELLEVUE ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5622
Mailing Address - Country:US
Mailing Address - Phone:920-965-0606
Mailing Address - Fax:920-965-0607
Practice Address - Street 1:2060 BELLEVUE ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5622
Practice Address - Country:US
Practice Address - Phone:920-965-0606
Practice Address - Fax:920-965-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40681207RH0000X
WI5123170332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5123170OtherNCPDP NUMBER
WI32850600Medicaid
WI000007655Medicare PIN