Healthcare Provider Details

I. General information

NPI: 1295780492
Provider Name (Legal Business Name): WISCONSIN PHLEBOLOGY MEDICAL GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10614 N PORT WASHINGTON RD
MEQUON WI
53092-5013
US

IV. Provider business mailing address

PO BOX 1602
NORTHBROOK IL
60065-1602
US

V. Phone/Fax

Practice location:
  • Phone: 262-834-0123
  • Fax:
Mailing address:
  • Phone: 847-593-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: NATHAN AMORUSO
Title or Position: SR VP REVENUE
Credential:
Phone: 847-593-8460