Healthcare Provider Details

I. General information

NPI: 1386698942
Provider Name (Legal Business Name): NEVINE RAMSIS YACOUB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

6308 8TH AVE ATTN: MEDICAL STAFF OFFICE
KENOSHA WI
53143-5031
US

V. Phone/Fax

Practice location:
  • Phone: 262-653-5300
  • Fax: 262-656-2963
Mailing address:
  • Phone: 262-653-5300
  • Fax: 262-656-2963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number50978-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: