Provider Demographics
NPI:1326086943
Name:WISCONSIN HEART GROUP
Entity Type:Organization
Organization Name:WISCONSIN HEART GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. & PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRODEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-827-9200
Mailing Address - Street 1:16650 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5920
Mailing Address - Country:US
Mailing Address - Phone:262-827-9200
Mailing Address - Fax:262-827-9858
Practice Address - Street 1:16650 W BLUEMOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5920
Practice Address - Country:US
Practice Address - Phone:262-827-9200
Practice Address - Fax:262-827-9858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32678600Medicaid
WI000068590Medicare ID - Type UnspecifiedWAUKESHA COUNTY GROUP NO.
WI32678600Medicaid