Healthcare Provider Details

I. General information

NPI: 1033679626
Provider Name (Legal Business Name): SAMUEL ENGELSGJERD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST STE 207
WAUKESHA WI
53188-3403
US

IV. Provider business mailing address

1111 DELAFIELD ST STE 207
WAUKESHA WI
53188-3403
US

V. Phone/Fax

Practice location:
  • Phone: 262-446-3593
  • Fax:
Mailing address:
  • Phone: 262-446-3593
  • Fax: 262-547-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number83235-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: