Healthcare Provider Details

I. General information

NPI: 1659289916
Provider Name (Legal Business Name): TWIN LAKES ANESTHESIA SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 GREEN BAY RD
KENOSHA WI
53144-1789
US

IV. Provider business mailing address

4824 GREEN BAY RD
KENOSHA WI
53144-1789
US

V. Phone/Fax

Practice location:
  • Phone: 262-299-6199
  • Fax: 262-293-6953
Mailing address:
  • Phone: 262-299-6199
  • Fax: 262-293-6953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CYRIL N PHILIP
Title or Position: MEMBER
Credential: MD
Phone: 262-299-6199