Provider Demographics
NPI:1265645600
Name:WISCONSIN FERTILITY AND REPRODUCTIVE SURGERY ASSOCIATES SC
Entity Type:Organization
Organization Name:WISCONSIN FERTILITY AND REPRODUCTIVE SURGERY ASSOCIATES SC
Other - Org Name:WISCONSIN FERTILITY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:OLIVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-824-0075
Mailing Address - Street 1:3146 DEMING WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1461
Mailing Address - Country:US
Mailing Address - Phone:608-824-0075
Mailing Address - Fax:608-829-0748
Practice Address - Street 1:3146 DEMING WAY
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-1461
Practice Address - Country:US
Practice Address - Phone:608-824-0075
Practice Address - Fax:608-829-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44212020261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center