Healthcare Provider Details

I. General information

NPI: 1679888911
Provider Name (Legal Business Name): DR. ANAS IBRAHIM GHOUSHEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N 92ND ST SUITE C 330
MILWAUKEE WI
53226-4875
US

IV. Provider business mailing address

999 N 92ND ST SUITE C 330
MILWAUKEE WI
53226-4875
US

V. Phone/Fax

Practice location:
  • Phone: 414-337-7757
  • Fax:
Mailing address:
  • Phone: 414-337-7757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number56308
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: