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General NPI Number Information
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NPI Number | 1356085104
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Entity Type | Organization
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Legal Business Name | THIRD COAST VASCULAR SC
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Dates
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Enumeration Date | 04/26/2022
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 1441 N TAYLOR DR
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City | SHEBOYGAN
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State | WI
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Zip | 53081-1989
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Country | US
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Telephone | 262-577-0250
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Fax | 262-577-0251
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Provider Business Mailing Address
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Address Line | 1441 N TAYLOR DR
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City | SHEBOYGAN
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State | WI
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Zip | 53081-1989
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Country | US
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Telephone | 920-298-2821
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Fax | 920-287-7500
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Authorized Official
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Title or Position | COO
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Name | TAHA SIDERS
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Credential | MD
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Telephone | 920-797-9378
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207PE0005X
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Taxonomy Name | Undersea and Hyperbaric Medicine (Emergency Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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