Provider Demographics
NPI:1124148499
Name:STANLEY, EDWIN C (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:C
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BIN 88399
Mailing Address - Street 2:
Mailing Address - City:MILAWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53288-0399
Mailing Address - Country:US
Mailing Address - Phone:901-448-1463
Mailing Address - Fax:901-448-1465
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2121
Practice Address - Country:US
Practice Address - Phone:715-847-2283
Practice Address - Fax:484-503-8200
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4511052085R0202X
390200000X
WI51762-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program