Provider Demographics
NPI:1083732788
Name:WISCONSIN VEIN CENTER AND MEDISPA, SC
Entity Type:Organization
Organization Name:WISCONSIN VEIN CENTER AND MEDISPA, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANJONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-746-9088
Mailing Address - Street 1:1231 GEORGE TOWNE DRIVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072
Mailing Address - Country:US
Mailing Address - Phone:262-746-9088
Mailing Address - Fax:262-746-9088
Practice Address - Street 1:1231 GEORGE TOWNE DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072
Practice Address - Country:US
Practice Address - Phone:262-746-9088
Practice Address - Fax:262-746-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68771Medicare ID - Type UnspecifiedGROUP NUMBER