Healthcare Provider Details

I. General information

NPI: 1598700817
Provider Name (Legal Business Name): KETTLE MORAINE ANESTHESIOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PLEASANT VALLEY RD
WEST BEND WI
53095-9274
US

IV. Provider business mailing address

200 E WASHINGTON ST P O BOX 8031
APPLETON WI
54911-5490
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-5533
  • Fax:
Mailing address:
  • Phone: 866-313-0337
  • Fax: 920-739-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JIM BROWNE
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 262-334-5533