Healthcare Provider Details

I. General information

NPI: 1952304727
Provider Name (Legal Business Name): SURGICAL SPECIALIST OF GREEN BAY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 S. VANBUREN ST SUITE 202
GREEN BAY WI
54301
US

IV. Provider business mailing address

720 S. VANBUREN ST SUITE 202
GREEN BAY WI
54301
US

V. Phone/Fax

Practice location:
  • Phone: 920-438-7155
  • Fax: 920-438-7193
Mailing address:
  • Phone: 920-438-7155
  • Fax: 920-438-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateWI

VIII. Authorized Official

Name: THOMAS V GEONARIS
Title or Position: MD
Credential: MD
Phone: 920-438-7155