Healthcare Provider Details

I. General information

NPI: 1114144466
Provider Name (Legal Business Name): CHITRA SADASIWAN BHOSEKAR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RIVERSIDE DR STE 200
GREEN BAY WI
54301-2300
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-9920
  • Fax: 920-433-9927
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number50264
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: