Healthcare Provider Details

I. General information

NPI: 1114459187
Provider Name (Legal Business Name): KYLE GREIBER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S PARK ST 4 TOWER
MADISON WI
53715
US

IV. Provider business mailing address

9403 W WISCONSIN AVE
MILWAUKEE WI
53226-3525
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-6676
  • Fax: 414-955-6528
Mailing address:
  • Phone: 608-575-1986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number69937
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: