MEDICARE: CARDIOTHORACIC SURGERY GROUP SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053388553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOTHORACIC SURGERY GROUP SC

Provider Business Mailing Address
First Line	:	2315 N LAKE DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4516
Country	:	US
Telephone Number	:	414-271-5119
Fax Number	:	414-271-3756

Provider Business Practice Location Address
First Line	:	2315 N LAKE DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4516
Country	:	US
Telephone Number	:	414-271-5119
Fax Number	:	414-271-3756

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT P MCMANUS
Credential	:	MD
Telephone Number	:	414-271-5119

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	08/22/2020

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