Provider Demographics
NPI:1851563472
Name:BRIAN VAN HOOZEN DO SC
Entity Type:Organization
Organization Name:BRIAN VAN HOOZEN DO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN HOOZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-982-7900
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-0096
Mailing Address - Country:US
Mailing Address - Phone:920-982-7900
Mailing Address - Fax:920-982-7995
Practice Address - Street 1:1505 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2187
Practice Address - Country:US
Practice Address - Phone:920-982-7900
Practice Address - Fax:920-982-7995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32699261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32699OtherLICENSE NUMBER
WI30054700Medicaid
WIBV0978417OtherDEA
WIB44275Medicare UPIN
WIBV0978417OtherDEA