Healthcare Provider Details

I. General information

NPI: 1083051163
Provider Name (Legal Business Name): URO GYN CONSULTATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25951 CIRCLE VIEW DR
RICHLAND CENTER WI
53581-4013
US

IV. Provider business mailing address

2020 COUNTY ROAD Z
BLUE MOUNDS WI
53517-9629
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-2138
  • Fax:
Mailing address:
  • Phone: 608-437-6035
  • Fax: 608-437-6035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name: KELLY KRUSE
Title or Position: OWNER
Credential: MS, APNP
Phone: 608-437-6035