Provider Demographics
NPI:1497705008
Name:WASCO, KEVIN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:EDWARD
Last Name:WASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 THEDA CLARK MEDICAL PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2763
Mailing Address - Country:US
Mailing Address - Phone:920-725-4527
Mailing Address - Fax:920-725-0991
Practice Address - Street 1:100 THEDA CLARK MEDICAL PLZ
Practice Address - Street 2:SUITE 400
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2763
Practice Address - Country:US
Practice Address - Phone:920-725-4527
Practice Address - Fax:920-725-0991
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI37076208600000X, 2086S0127X, 2086S0129X, 208C00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32162500Medicaid
WI000071445Medicare PIN
WI000471445Medicare PIN
020043962Medicare ID - Type UnspecifiedRAILROAD
G13057Medicare UPIN