Healthcare Provider Details

I. General information

NPI: 1831420587
Provider Name (Legal Business Name): WATERTOWN HEART INSTITUTE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HOSPITAL DRIVE
WATERTOWN WI
53098-3303
US

IV. Provider business mailing address

2500 LAYTON AVENUE SUITE: 200
MILWAUKEE WI
53221-5434
US

V. Phone/Fax

Practice location:
  • Phone: 920-262-4449
  • Fax: 920-262-4533
Mailing address:
  • Phone: 414-282-5105
  • Fax: 414-282-8670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36011-20
License Number StateWI

VIII. Authorized Official

Name: DR. SALIM M. SHAMMO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 414-282-5105