Provider Demographics
NPI:1013738509
Name:KINETIC SPINE AND PAIN SC
Entity type:Organization
Organization Name:KINETIC SPINE AND PAIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-232-7268
Mailing Address - Street 1:4491 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1611
Mailing Address - Country:US
Mailing Address - Phone:414-999-3815
Mailing Address - Fax:
Practice Address - Street 1:4491 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1611
Practice Address - Country:US
Practice Address - Phone:414-999-3815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-18
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty