Organization
CENTRAL WISCONSIN ANESTHESI
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CAROLYN J DOMKE (OFFICE MANAGER)
(920) 361-5538
Entity
Organization
Contact information
Practice address
225 MEMORIAL DR, BERLIN, WI 54923-1243
(920) 361-5538
(920) 361-5499
Mailing address
225 MEMORIAL DR, BERLIN, WI 54923-1243
(920) 361-5538
(920) 361-5499
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
—
—
207LP2900X
Pain Medicine (Anesthesiology) Physician
—
—
367500000X
Certified Registered Nurse Anesthetist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000021415
MEDICARE
WI
01
—
000026095
MEDICARE
WI
05
—
43419700
—
WI
Enumeration date
10/12/2006
Last updated
11/05/2012
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