Provider Demographics
NPI:1538177480
Name:PIERCE, CAROL ADA (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ADA
Last Name:PIERCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-742-6098
Practice Address - Street 1:2817 NEW PINERY ROAD
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-742-6098
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI24244020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C46882Medicare UPIN