Provider Demographics
NPI:1942277538
Name:BOSCOBEL CLINIC, S.C.
Entity Type:Organization
Organization Name:BOSCOBEL CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:FAST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-375-4144
Mailing Address - Street 1:208 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1648
Mailing Address - Country:US
Mailing Address - Phone:608-375-4144
Mailing Address - Fax:608-375-5629
Practice Address - Street 1:208 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1648
Practice Address - Country:US
Practice Address - Phone:608-375-4144
Practice Address - Fax:608-375-5629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
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
WI32687700Medicaid
WI24051Medicare ID - Type UnspecifiedMEDICARE ID#