Healthcare Provider Details

I. General information

NPI: 1598863334
Provider Name (Legal Business Name): GEORGE E VIDALAKIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N BARTLETT ST
SHAWANO WI
54166-2127
US

IV. Provider business mailing address

100 COUNTY ROAD B
SHAWANO WI
54166-7072
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-2111
  • Fax: 715-526-9174
Mailing address:
  • Phone: 715-526-8120
  • Fax: 715-526-9174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number25046
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: