Basic Information
Provider Information | |||||||||
NPI: | 1710180138 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOMAH VA MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10222 EMERSON RD | ||||||||
Address2: |   | ||||||||
City: | TOMAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546604235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083723971 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10222 EMERSON RD | ||||||||
Address2: | 500E VETERANS ST | ||||||||
City: | TOMAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546604235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083723971 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RIOS | ||||||||
AuthorizedOfficialFirstName: | BRUNO | ||||||||
AuthorizedOfficialMiddleName: | ENRIQUE | ||||||||
AuthorizedOfficialTitleorPosition: | MD | ||||||||
AuthorizedOfficialTelephone: | 6083742807 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 7159 | PR | Y |   | Hospital Units | Rehabilitation Unit |   |
No ID Information.