Healthcare Provider Details

I. General information

NPI: 1780684647
Provider Name (Legal Business Name): DRS WAGNER GOODMAN PASCH AND PACKMAN LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 N PORT WASHINGTON RD SUITE 151
MILWAUKEE WI
53217-5474
US

IV. Provider business mailing address

5150 N PORT WASHINGTON RD SUITE 151
MILWAUKEE WI
53217-5474
US

V. Phone/Fax

Practice location:
  • Phone: 414-332-1000
  • Fax: 414-332-1005
Mailing address:
  • Phone: 414-332-1000
  • Fax: 414-332-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: MR. JOSEPH JAY GOODMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 414-332-1000