Basic Information
| Provider Information | |||||||||
| NPI: | 1720056146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PODIATRY ASSOCIATES OF WAUSAU, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1445 MERRILL AVE | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544012646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156752321 | ||||||||
| FaxNumber: | 7156756530 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 CHIPPEWA DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545019503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153626813 | ||||||||
| FaxNumber: | 7153626813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOURDAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7156752321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | DME SUPPLIER # | 01 | 0427710002 | OTHER |