Healthcare Provider Details

I. General information

NPI: 1023065836
Provider Name (Legal Business Name): GREEN BAY ANESTHESIA ASSOC. SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S VAN BUREN ST
GREEN BAY WI
54301-3526
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4257
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-0111
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax: 262-782-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN B SKALETSKI
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 920-433-0111