Provider Demographics
NPI:1053389544
Name:WATERTOWER PAIN CONSULTANTS, SC
Entity type:Organization
Organization Name:WATERTOWER PAIN CONSULTANTS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONATELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-962-6700
Mailing Address - Street 1:575 W RIVER WOODS PKWY
Mailing Address - Street 2:#205
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 W RIVER WOODS PKWY
Practice Address - Street 2:#205
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1003
Practice Address - Country:US
Practice Address - Phone:414-962-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21298700Medicaid
52D1088766OtherCLIA
000001438Medicare PIN