Provider Demographics
NPI:1316937519
Name:STATELINE ANESTHESIOLOGISTS SC
Entity type:Organization
Organization Name:STATELINE ANESTHESIOLOGISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMSON
Authorized Official - Middle Name:C
Authorized Official - Last Name:TSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-362-7444
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53512-0686
Mailing Address - Country:US
Mailing Address - Phone:608-362-7444
Mailing Address - Fax:608-362-0417
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:BELOIT MEMORIAL HOSPITAL
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-364-5355
Practice Address - Fax:608-362-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI541844OtherDEANCARE
WI32828100Medicaid
WI541844OtherDEANCARE