Provider Demographics
NPI:1417419359
Name:GYNECOLOGY ASSOCIATES OF WISCONSIN
Entity Type:Organization
Organization Name:GYNECOLOGY ASSOCIATES OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCAVOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-213-2102
Mailing Address - Street 1:5315 FOX GLEN CT
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53146-3935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10900 W POTTER RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3424
Practice Address - Country:US
Practice Address - Phone:414-213-2102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034597Medicaid
WI34815000Medicaid
WI32134000Medicaid
WI32536900Medicaid
WI100049142Medicaid
WI100057159Medicaid