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General NPI Number Information
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NPI Number | 1396831343
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Entity Type | Organization
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Legal Business Name | KENOSHA UROLOGY CLINIC, S.C.
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 06/03/2008
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Provider Practice Location Address
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Address Line | 6308 8TH AVE SUITE 503
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City | KENOSHA
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State | WI
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Zip | 53143-5031
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Country | US
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Telephone | 262-656-8213
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Fax | 262-656-8233
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Provider Business Mailing Address
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Address Line | 6308 8TH AVE SUITE 503
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City | KENOSHA
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State | WI
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Zip | 53143-5031
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Country | US
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Telephone | 262-656-8213
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Fax | 262-656-8233
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | NED R. NOVSAM
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Credential | M.D.
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Telephone | 262-656-8213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 308295
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License Number State | WI
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