Healthcare Provider Details

I. General information

NPI: 1871665091
Provider Name (Legal Business Name): WISCONSIN REHABILITATION MEDICINE PROFESSIONALS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 LAKEVIEW RIDGE RD
BELGIUM WI
53004-9423
US

IV. Provider business mailing address

PO BOX 1790
BROOKFIELD WI
53008-1790
US

V. Phone/Fax

Practice location:
  • Phone: 262-285-3888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: SRIDHAR V VASUDEVAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-285-3888