Healthcare Provider Details

I. General information

NPI: 1962849711
Provider Name (Legal Business Name): URO GYN CONSULTATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 COUNTY ROAD CH
DODGEVILLE WI
53533-9108
US

IV. Provider business mailing address

2020 COUNTY ROAD Z
BLUE MOUNDS WI
53517-9629
US

V. Phone/Fax

Practice location:
  • Phone: 608-935-3321
  • Fax:
Mailing address:
  • Phone: 608-437-6035
  • Fax: 608-437-6035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number84725-30
License Number StateWI

VIII. Authorized Official

Name: KELLY KRUSE
Title or Position: OWNER
Credential: MS, APNP
Phone: 608-437-6035