Provider Demographics
NPI:1225153620
Name:SOUTHEAST WISCONSIN AMBULATORY SURGICAL CENTER S C
Entity Type:Organization
Organization Name:SOUTHEAST WISCONSIN AMBULATORY SURGICAL CENTER S C
Other - Org Name:SOUTHEAST WISCONSIN SURGICAL SUITES SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CERNAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-697-4301
Mailing Address - Street 1:10105 74TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7519
Mailing Address - Country:US
Mailing Address - Phone:262-697-4301
Mailing Address - Fax:262-925-8409
Practice Address - Street 1:10105 74TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7519
Practice Address - Country:US
Practice Address - Phone:262-697-4301
Practice Address - Fax:262-925-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52D1008619261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical