Basic Information
| Provider Information | |||||||||
| NPI: | 1598032328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT MIDWEST PAIN SPECIALISTS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627874050 | ||||||||
| FaxNumber: | 2627826040 | ||||||||
| Practice Location | |||||||||
| Address1: | 17495 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627874050 | ||||||||
| FaxNumber: | 2627826040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2011 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | FOLLANSBEE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2627874050 | ||||||||
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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 | 207LP2900X | 32725 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.