Provider Demographics
NPI:1194473066
Name:ASCENSION MEDICAL GROUP-SOUTHEAST WISCONSIN INC
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP-SOUTHEAST WISCONSIN INC
Other - Org Name:AMG ANESTHESIA
Other - Org Type:Other Name
Authorized Official - Title/Position:VP-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3000
Mailing Address - Street 1:400 W RIVER WOODS PKWY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-585-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-10
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty