Provider Demographics
NPI:1174531123
Name:PREVENTIVE CARDIOLOGY OF CENTRAL WISCONSIN LLC
Entity type:Organization
Organization Name:PREVENTIVE CARDIOLOGY OF CENTRAL WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PERRIGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-370-5433
Mailing Address - Street 1:BOX 2003
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-2003
Mailing Address - Country:US
Mailing Address - Phone:715-370-5433
Mailing Address - Fax:715-359-3485
Practice Address - Street 1:3910 WESTON AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476
Practice Address - Country:US
Practice Address - Phone:715-370-5433
Practice Address - Fax:715-359-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22225020020207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34009800Medicaid
WI34009800Medicaid