Provider Demographics
NPI:1881605335
Name:CARLSON GI CLINIC
Entity type:Organization
Organization Name:CARLSON GI CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:715-421-1001
Mailing Address - Street 1:420 DEWEY STREET
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-0005
Mailing Address - Country:US
Mailing Address - Phone:715-421-1001
Mailing Address - Fax:715-421-3004
Practice Address - Street 1:420 DEWEY STREET
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-0005
Practice Address - Country:US
Practice Address - Phone:715-421-1001
Practice Address - Fax:715-421-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty