Provider Demographics
NPI:1154492668
Name:GS MICELI DPM, SC
Entity Type:Organization
Organization Name:GS MICELI DPM, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GIUSEPPE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MICELI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-925-6565
Mailing Address - Street 1:PO BOX 580149
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-8011
Mailing Address - Country:US
Mailing Address - Phone:262-925-6565
Mailing Address - Fax:262-697-4291
Practice Address - Street 1:7201 GREEN BAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3532
Practice Address - Country:US
Practice Address - Phone:262-925-6565
Practice Address - Fax:262-697-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI524213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43208700Medicaid
WI43208700Medicaid
WI000032056Medicare ID - Type Unspecified
WI5881250001Medicare NSC