Basic Information
| Provider Information | |||||||||
| NPI: | 1245410851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER WOUND SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9875 S FRANKLIN DR | ||||||||
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| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531328895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148582200 | ||||||||
| FaxNumber: | 4148582230 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 GOLF RD | ||||||||
| Address2: | |||||||||
| City: | PEWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530725590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625242784 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2007 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | NIEZGODA | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2625242784 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
No ID Information.