Healthcare Provider Details

I. General information

NPI: 1902867799
Provider Name (Legal Business Name): GREGG E KISSEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 WINNEBAGO ST
MADISON WI
53704-5341
US

IV. Provider business mailing address

2125 FOX AVE
MADISON WI
53711-1920
US

V. Phone/Fax

Practice location:
  • Phone: 608-828-7603
  • Fax: 608-242-6848
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40170
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: