Healthcare Provider Details

I. General information

NPI: 1053884478
Provider Name (Legal Business Name): HEART AND VASCULAR OF WISCONSIN, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5045 W GRANDE MARKET DR
APPLETON WI
54913-8517
US

IV. Provider business mailing address

PO BOX 610
GREEN BAY WI
54305-0610
US

V. Phone/Fax

Practice location:
  • Phone: 920-886-9380
  • Fax: 920-886-9381
Mailing address:
  • Phone: 920-886-9380
  • Fax: 920-886-9381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: LARRY SOBAL
Title or Position: CEO
Credential:
Phone: 904-574-6211