Healthcare Provider Details

I. General information

NPI: 1467529917
Provider Name (Legal Business Name): GBR SHEBOYGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUPERIOR AVE
SHEBOYGAN WI
53081-1948
US

IV. Provider business mailing address

2941 S RIDGE RD
GREEN BAY WI
54304-5517
US

V. Phone/Fax

Practice location:
  • Phone: 920-964-0480
  • Fax: 920-336-8093
Mailing address:
  • Phone: 920-336-4096
  • Fax: 920-336-8093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: JIMMY DADO
Title or Position: AUTHORIZED OFFICAL
Credential: CFO
Phone: 614-325-8899