Healthcare Provider Details

I. General information

NPI: 1154492668
Provider Name (Legal Business Name): GS MICELI DPM, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 GREEN BAY RD SUITE A
KENOSHA WI
53142-3532
US

IV. Provider business mailing address

PO BOX 580149
PLEASANT PRAIRIE WI
53158-8011
US

V. Phone/Fax

Practice location:
  • Phone: 262-925-6565
  • Fax: 262-697-4291
Mailing address:
  • Phone: 262-925-6565
  • Fax: 262-697-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number524
License Number StateWI

VIII. Authorized Official

Name: DR. GIUSEPPE S MICELI
Title or Position: OWNER
Credential: D.P.M.
Phone: 262-925-6565