Healthcare Provider Details

I. General information

NPI: 1508312570
Provider Name (Legal Business Name): AZH VASCULAR CENTER MKE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W LAYTON AVE SUITE 40
MILWAUKEE WI
53221-5420
US

IV. Provider business mailing address

2500 W LAYTON AVE SUITE 40
MILWAUKEE WI
53221-5420
US

V. Phone/Fax

Practice location:
  • Phone: 262-577-0250
  • Fax: 262-577-0251
Mailing address:
  • Phone: 262-577-0250
  • Fax: 262-577-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: VALERIE WAGNER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 262-577-0250