Provider Demographics
NPI:1467529917
Name:GBR SHEBOYGAN LLC
Entity Type:Organization
Organization Name:GBR SHEBOYGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DADO
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:614-325-8899
Mailing Address - Street 1:2941 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5517
Mailing Address - Country:US
Mailing Address - Phone:920-336-4096
Mailing Address - Fax:920-336-8093
Practice Address - Street 1:3100 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1948
Practice Address - Country:US
Practice Address - Phone:920-964-0480
Practice Address - Fax:920-336-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21284500Medicaid
WI21284500Medicaid