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General NPI Number Information
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NPI Number | 1780940478
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Entity Type | Organization
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Legal Business Name | SURGICAL ASSOCIATES OF KENOSHA S. C.
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Dates
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Enumeration Date | 04/06/2012
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Last Update Date | 04/06/2012
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Provider Practice Location Address
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Address Line | 7600 2ND AVE
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City | KENOSHA
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State | WI
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Zip | 53143-6067
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Country | US
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Telephone | 262-656-8217
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Fax |
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Provider Business Mailing Address
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Address Line | 7600 2ND AVE
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City | KENOSHA
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State | WI
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Zip | 53143-6067
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Country | US
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Telephone | 262-656-8217
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROGER THOMAS PACANOWSKI
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Credential | M.D.
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Telephone | 262-656-8217
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 16095
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License Number State | WI
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