Provider Demographics
NPI:1225318090
Name:CTVSA WISCONSIN S.C.
Entity Type:Organization
Organization Name:CTVSA WISCONSIN S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATROKLOS
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PAPPAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-346-4040
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 3060
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-2700
Practice Address - Fax:262-656-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty