Healthcare Provider Details

I. General information

NPI: 1740710748
Provider Name (Legal Business Name): ROBERT JAMES CORLISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST. VINCENT FMC, 140EAST COOK ST.
PORTAGE WI
53901
US

IV. Provider business mailing address

N 602 COUNTY ROAD T
ENDEAVOR WI
53930-9526
US

V. Phone/Fax

Practice location:
  • Phone: 608-697-0806
  • Fax:
Mailing address:
  • Phone: 608-697-0806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number14145
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: