1396774543 NPI number — WISCONSIN SURGERY CENTER LLC

Table of content: (NPI 1396774543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396774543 NPI number — WISCONSIN SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISCONSIN SURGERY CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396774543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 210140
Provider Second Line Business Mailing Address:
4131 W LOOMIS RD STE 300
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-325-3725
Provider Business Mailing Address Fax Number:
414-325-3720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3305 S 20TH ST
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-384-2100
Provider Business Practice Location Address Fax Number:
414-384-2700
Provider Enumeration Date:
07/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAL
Authorized Official First Name:
VISHAL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
414-325-3737

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41913800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".