Basic Information
| Provider Information | |||||||||
| NPI: | 1922497908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUESTONE PHYSICIAN SERVICES WISCONSIN SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 MAIN ST N STE 300 | ||||||||
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| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513421039 | ||||||||
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| Practice Location | |||||||||
| Address1: | 342 N WATER ST STE 600 | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532025715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513421039 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOEHLER | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF BLUESTONE NATIONAL, LL | ||||||||
| AuthorizedOfficialTelephone: | 6512097758 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.