NPIMap

Organization Active NPI

Wisconsin Spine and Pain SC

  • Interventional Pain Medicine Physician
  • Sheboygan, WI
National Provider Identifier
1790309276
Registry record updated Sep 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
WISCONSIN SPINE AND PAIN SC
Practice address
2124 Kohler Memorial Dr Ste 110
Sheboygan, WI 53081-3174
Phone
(920) 204-6758
NPI assigned
Jun 1, 2020
Last updated
Sep 27, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 27, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michael W Jung, MDNPI 1861665747
Title
Owner
Phone
(414) 455-1153

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Pain Medicine Physician 208VP0014X NU Primary

Addresses

Primary practice location

2124 Kohler Memorial Dr Ste 110
Sheboygan, WI 53081-3174

Mailing address

Dept CH 17057
Palatine, IL 60055-7057
Phone (414) 455-1153

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200806002745 WI Part B Supplier - Clinic/Group Practice 0345665469 Receives reassigned benefits from 35 practitioners
Practice locations: Waukesha, WI; West Bend, WI; Mequon, WI; Sheboygan, WI; Green Bay, WI; Appleton, WI

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

2595 Development Dr
Green Bay, WI 54311
Phone (920) 338-2120

2124 Kohler Memorial Dr
Ste 100
Sheboygan, WI 53081
Phone (920) 452-7246

N14W23800 Stone Ridge Dr
Ste 120
Waukesha, WI 53188

Practitioners & affiliated clinicians

Practitioners 43

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 43

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1590969600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727395200000",
    "number": "1790309276",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "DEPT CH 17057",
            "city": "PALATINE",
            "state": "IL",
            "postal_code": "600557057",
            "telephone_number": "414-455-1153"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2124 KOHLER MEMORIAL DR STE 110",
            "city": "SHEBOYGAN",
            "state": "WI",
            "postal_code": "530813174",
            "telephone_number": "920-204-6758"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WISCONSIN SPINE AND PAIN SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-06-01",
        "last_updated": "2024-09-27",
        "certification_date": "2024-09-26",
        "status": "A",
        "authorized_official_last_name": "JUNG",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "414-455-1153",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208VP0014X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sheboygan, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.