Healthcare Provider Details

I. General information

NPI: 1124002282
Provider Name (Legal Business Name): PAUL G SPOTTSWOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 02/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4266
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-2011
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number27329-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: