MEDICARE: KENOSHA EMERGENCY PHYSICIANS, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207P00000X	Emergency Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CD9325	OTHER	WI	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110009911	OTHER	WI	WEA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	137497601	OTHER	WI	OWCP

General Provider Information

NPI Number	:	1942259726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENOSHA EMERGENCY PHYSICIANS, LLC

Provider Business Mailing Address
First Line	:	111 E WISCONSIN AVE
Second Line	:	SUITE 2000
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4815
Country	:	US
Telephone Number	:	954-838-2371
Fax Number	:	414-290-6755

Provider Business Practice Location Address
First Line	:	9555 76TH ST
Second Line	:
City	:	PLEASANT PRAIRIE
State	:	WI
Zip	:	53158-1984
Country	:	US
Telephone Number	:	414-290-6718
Fax Number	:	414-290-6755

Authorized Official
Title or Position	:	OFFICER
Name	:	KAREN VAUGHN
Credential	:
Telephone Number	:	973-251-1132

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	03/30/2023

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Directions to “KENOSHA EMERGENCY PHYSICIANS, LLC ” Practice Location

Language	Start Address	Practice Location

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