Basic Information
| Provider Information | |||||||||
| NPI: | 1184646051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST WISCONSIN ANESTHESIOLOGISTS, SC | ||||||||
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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: | 1100 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152341515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAETHER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7152341515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 208VP0014X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32881600 | 05 | WI | MEDICAID |