Healthcare Provider Details

I. General information

NPI: 1356085104
Provider Name (Legal Business Name): THIRD COAST VASCULAR SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N TAYLOR DR
SHEBOYGAN WI
53081-1989
US

IV. Provider business mailing address

1441 N TAYLOR DR
SHEBOYGAN WI
53081-1989
US

V. Phone/Fax

Practice location:
  • Phone: 262-577-0250
  • Fax: 262-577-0251
Mailing address:
  • Phone: 920-298-2821
  • Fax: 920-287-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TAHA SIDERS
Title or Position: COO
Credential: MD
Phone: 920-797-9378