Basic Information
| Provider Information | |||||||||
| NPI: | 1013964808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRADLEY N. HAUGSTAD, M.D., S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627874026 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6308 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531435031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626562011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAUGSTAD | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2626562011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21291500 | 05 | WI | MEDICAID |