Provider Demographics
NPI:1992800791
Name:INTERVENTIONAL PAIN SPECIALISTS OF WISCONSIN, SC
Entity type:Organization
Organization Name:INTERVENTIONAL PAIN SPECIALISTS OF WISCONSIN, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRENDEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:715-234-7246
Mailing Address - Street 1:2021 CENEX DR UNIT J
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-1892
Mailing Address - Country:US
Mailing Address - Phone:715-234-7246
Mailing Address - Fax:715-234-7242
Practice Address - Street 1:2021 CENEX DR UNIT J
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1892
Practice Address - Country:US
Practice Address - Phone:715-234-7246
Practice Address - Fax:715-234-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34036207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31913700Medicaid
WI397524621000OtherBLUE CROSS WI
WI34036OtherWI LICENSE NUMBER
WIBB3535842OtherDEA
WIBB3535842OtherDEA
WI31913700Medicaid
WI397524621000OtherBLUE CROSS WI