=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033679626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ENGELSGJERD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2019
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 DELAFIELD ST STE 207
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-446-3593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 DELAFIELD ST STE 207
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-446-3593
-----------------------------------------------------
Fax | 262-547-0379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 83235-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------