Healthcare Provider Details

I. General information

NPI: 1679546584
Provider Name (Legal Business Name): REGIONAL GENERAL & VASCULAR SURGEONS, S. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 CORPORATE CENTER DR SUITE 200
OCONOMOWOC WI
53066-4845
US

IV. Provider business mailing address

1185 CORPORATE CENTER DR SUITE 200
OCONOMOWOC WI
53066-4845
US

V. Phone/Fax

Practice location:
  • Phone: 262-567-1499
  • Fax: 262-567-4502
Mailing address:
  • Phone: 262-567-1499
  • Fax: 262-567-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. KIM M BEDUZE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 262-567-1499