Healthcare Provider Details

I. General information

NPI: 1255796991
Provider Name (Legal Business Name): CMWL2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1688 N CASALOMA DR
APPLETON WI
54913-8245
US

IV. Provider business mailing address

2641 DEVELOPMENT DR
GREEN BAY WI
54311-4240
US

V. Phone/Fax

Practice location:
  • Phone: 920-707-5100
  • Fax:
Mailing address:
  • Phone: 920-338-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number43795
License Number StateWI

VIII. Authorized Official

Name: DR. HERBERT S COUSSONS
Title or Position: OWNER
Credential: MD
Phone: 920-338-6868