Healthcare Provider Details

I. General information

NPI: 1629123716
Provider Name (Legal Business Name): AMY R DYSART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MEMORIAL DR
TWO RIVERS WI
54241-3923
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-793-6500
  • Fax: 920-793-6501
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-165653
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number43777
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: