Healthcare Provider Details

I. General information

NPI: 1780032219
Provider Name (Legal Business Name): AZH WOUND CENTER MKE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W LAYTON AVE STE 30
MILWAUKEE WI
53221-5436
US

IV. Provider business mailing address

2500 W LAYTON AVE SUITE 30
MILWAUKEE WI
53221-5420
US

V. Phone/Fax

Practice location:
  • Phone: 262-577-0250
  • Fax: 262-577-0251
Mailing address:
  • Phone: 414-269-5336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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

VIII. Authorized Official

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