CMS-1500 Box 24J / 33a • NPI
1750206496
Type 2 Organization (Box 32a/33a)
HIPAA NUCC Taxonomy • CMS Code
363LP2300X (CMS 50)
Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Primary Care
Box 32 Service Location & ZIP+4
2570 GRACIE DR STE 107, BALDWIN, WI, 54002-4403
✓ 9-Digit EDI 837 ZIP+4 (54002-4403)
✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR:
NPI
1750206496 (MEDIVERSE HEALTH & WELLNESS LLC) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).
CMS Medicare Order & Referring PECOS Eligibility
Official CMS NPPES Credential & Practice Profile
| 10-Digit NPI Number | 1750206496 (NPI-2 Organization / Facility) |
|---|---|
| Provider / Legal Name | MEDIVERSE HEALTH & WELLNESS LLC |
| Plain-English Specialty | Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Primary Care NUCC Code: 363LP2300X (Nurse Practitioner, Primary Care) |
| Certifying / Licensing Body | State Medical / Healthcare Licensing Board & National Specialty Board |
| Practice Location Address | 2570 GRACIE DR STE 107, BALDWIN, WI, 54002-4403 |
| Practice Telephone / Fax | Tel: (715) 977-2312 | Fax: (715) 487-3131 |
| Administrative Mailing Address | W4401 STATE ROAD 29, SPRING VALLEY, WI, 54767-8311 |
| Enumeration & Last Sync | Enumerated: 2026-08-11 | CMS Record Updated: 2026-08-11 |
| Authorized Official | JESSICA STOIBER (Owner) |
Clinic Location, Accessibility & Directions
📍 Practice Location & Patient Access
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Plain-English Taxonomy & CMS Crosswalk (363LP2300X)
What Does Taxonomy Code 363LP2300X Mean?
In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363LP2300X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Primary Care"
Specialty Clinical Procedures & Therapeutic Classes
Standard Scope of Care (MEDIVERSE HEALTH & WELLNESS LLC)
Typical CPT / Diagnostic Procedures:- Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
- Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
- Preventive Screening, Patient Counseling & Multidisciplinary Referral
- Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)
All Registered NUCC Taxonomies & State Licenses
| Taxonomy Code & Plain-English Description | State License & Primary Status |
|---|---|
261QI0500X — Clinic/Center, Infusion TherapyPlain English: Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center | State: N/A | License: Verified | Primary: Secondary |
261QP2300X — Clinic/Center, Primary CarePlain English: Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center | State: N/A | License: Verified | Primary: Secondary |
363LP2300X — Nurse Practitioner, Primary CarePlain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Primary Care | State: N/A | License: Verified | Primary: Yes (Primary) |
Medical Billing, RCM & Hospital Credentialing Teams:
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