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NPI Code Detail

MEDICARE: GBR SHEBOYGAN LLC

MEDICARE: GBR SHEBOYGAN LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0204XVascular & Interventional Radiology PhysicianWI
22085R0202XDiagnostic Radiology PhysicianWI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1467529917
Entity Type Code : Organization
Provider Name (Legal Business Name) : GBR SHEBOYGAN LLC
Provider Business Mailing Address
First Line : 2941 S RIDGE RD
Second Line :
City : GREEN BAY
State : WI
Zip : 54304-5517
Country : US
Telephone Number : 920-336-4096
Fax Number : 920-336-8093
Provider Business Practice Location Address
First Line : 3100 SUPERIOR AVE
Second Line :
City : SHEBOYGAN
State : WI
Zip : 53081-1948
Country : US
Telephone Number : 920-964-0480
Fax Number : 920-336-8093
Authorized Official
Title or Position : DIRECTOR OF REVENUE CYCLE
Name : JIMMY DADO JR.
Credential :
Telephone Number : 614-325-8899
Provider Enumeration Date : 11/29/2006
Last Update Date : 05/29/2026

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