Provider Demographics
NPI:1851570725
Name:BRETT EGELSEER
Entity Type:Organization
Organization Name:BRETT EGELSEER
Other - Org Name:ADVANCED SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-467-6281
Mailing Address - Street 1:11203 N BUNTROCK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1857
Mailing Address - Country:US
Mailing Address - Phone:262-512-1661
Mailing Address - Fax:262-512-1663
Practice Address - Street 1:11203 N BUNTROCK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-1857
Practice Address - Country:US
Practice Address - Phone:262-512-1661
Practice Address - Fax:262-512-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2649-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38898300Medicaid
WI38898300Medicaid