Provider Demographics
NPI:1396831343
Name:KENOSHA UROLOGY CLINIC, S.C.
Entity Type:Organization
Organization Name:KENOSHA UROLOGY CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NED
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOVSAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-656-8213
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-8213
Mailing Address - Fax:262-656-8233
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-8213
Practice Address - Fax:262-656-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI308295208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32729100Medicaid
WI32143Medicare ID - Type Unspecified
WI32729100Medicaid