Provider Demographics
NPI:1649511304
Name:WAUWATOSA PAIN MANAGEMENT , LLC
Entity type:Organization
Organization Name:WAUWATOSA PAIN MANAGEMENT , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-530-2477
Mailing Address - Street 1:6005 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1527
Mailing Address - Country:US
Mailing Address - Phone:414-530-2477
Mailing Address - Fax:414-771-6311
Practice Address - Street 1:6005 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1527
Practice Address - Country:US
Practice Address - Phone:414-530-2477
Practice Address - Fax:414-771-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain