Provider Demographics
NPI:1750876249
Name:MPAC OF WISCONSIN SC
Entity type:Organization
Organization Name:MPAC OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:888-660-4425
Mailing Address - Street 1:2045 W GRAND AVE STE B
Mailing Address - Street 2:#28354
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1577
Mailing Address - Country:US
Mailing Address - Phone:888-705-8722
Mailing Address - Fax:888-705-8722
Practice Address - Street 1:3000 N HALSTED ST STE 803
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6185
Practice Address - Country:US
Practice Address - Phone:888-705-8722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty