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Www. paindiagnostics. net Phone 715 251-1780 Fax 715 251-1787 A Division of Wisconsin Michigan Physicians Vijay Singh MD Katherine Liao MD John Birgiolas MD Main Office 1601 Roosevelt Road Niagara WI 54151 Satellite Clinics in Iron River and Escanaba REFERRAL FORM Date Patient Name DOB Address SS City State Zip Phone Responsible Party Cell Primary Insurance Policy Group Secondary Insurance PLEASE ONLY CHECK ONE Request for Opinion Please provide an opinion and consult for the above named...
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