Basic Information
| Provider Information | |||||||||
| NPI: | 1568450559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REEDSBURG PHYSICIANS GROUP, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 N DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539592214 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1900 N DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539592214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085246477 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | OSCAR | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6085246477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32717800 | 05 | WI | MEDICAID |