Healthcare Provider Details

I. General information

NPI: 1326086943
Provider Name (Legal Business Name): WISCONSIN HEART GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16650 W BLUEMOUND RD SUITE 200
BROOKFIELD WI
53005-5920
US

IV. Provider business mailing address

16650 W BLUEMOUND RD SUITE 200
BROOKFIELD WI
53005-5920
US

V. Phone/Fax

Practice location:
  • Phone: 262-827-9200
  • Fax: 262-827-9858
Mailing address:
  • Phone: 262-827-9200
  • Fax: 262-827-9858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID L. GRODEN
Title or Position: M.D. & PRESIDENT
Credential: M.D.
Phone: 262-827-9200