Healthcare Provider Details

I. General information

NPI: 1275598302
Provider Name (Legal Business Name): WAUWATOSA SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 W POTTER RD
WAUWATOSA WI
53226-3424
US

IV. Provider business mailing address

10900 W POTTER RD
WAUWATOSA WI
53226-3424
US

V. Phone/Fax

Practice location:
  • Phone: 414-774-9227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY WILLBUR
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 414-208-4456