Basic Information
| Provider Information | |||||||||
| NPI: | 1134753411 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROACTIVE MD WI SC | ||||||||
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| OtherOrganizationName: | PROACTIVE MD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 ALLAWOOD CT | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296816207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
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| Practice Location | |||||||||
| Address1: | BRAKEBUSH HEALTH CENTER | ||||||||
| Address2: | N4993 6TH DR. | ||||||||
| City: | WESTFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009332121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2020 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOC. OPS MGR | ||||||||
| AuthorizedOfficialTelephone: | 8645010751 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.