Provider Demographics
NPI:1043515257
Name:ADVANCED INTERVENTIONS, SC
Entity Type:Organization
Organization Name:ADVANCED INTERVENTIONS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GAYLORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-946-2505
Mailing Address - Street 1:4131 W LOOMIS RD
Mailing Address - Street 2:STE 210
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2057
Mailing Address - Country:US
Mailing Address - Phone:920-946-2505
Mailing Address - Fax:
Practice Address - Street 1:805 N MAYFAIR RD
Practice Address - Street 2:ADVANCED INTERVENTIONS VASCARE
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4241
Practice Address - Country:US
Practice Address - Phone:414-988-6773
Practice Address - Fax:414-988-6779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty