Healthcare Provider Details

I. General information

NPI: 1528053295
Provider Name (Legal Business Name): WISCONSIN CARDIOVASCULAR GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 N LAKE DR
MILWAUKEE WI
53211-4518
US

IV. Provider business mailing address

2315 N LAKE DR
MILWAUKEE WI
53211-4518
US

V. Phone/Fax

Practice location:
  • Phone: 414-271-1633
  • Fax: 414-271-5071
Mailing address:
  • Phone: 414-271-1633
  • Fax: 414-271-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number29385
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number28836
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number45947
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number21728
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number22535
License Number StateWI

VIII. Authorized Official

Name: DR. DAVID W. GRAMBOW
Title or Position: CARIOLOGIST
Credential: M. D.
Phone: 414-271-1633