Healthcare Provider Details

I. General information

NPI: 1083490395
Provider Name (Legal Business Name): VITUITY-WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10256 OLD GREEN BAY RD STE 140
PLEASANT PRAIRIE WI
53158-2814
US

IV. Provider business mailing address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

V. Phone/Fax

Practice location:
  • Phone: 262-217-3455
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID BIRDSALL
Title or Position: VICE PRESIDENT AND SECRETARY
Credential: MD
Phone: 510-350-2600