Provider Demographics
NPI:1508988239
Name:MILWAUKEE GENERAL & VASCULAR SURGERY SC
Entity Type:Organization
Organization Name:MILWAUKEE GENERAL & VASCULAR SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:EKBOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-778-6670
Mailing Address - Street 1:10400 W NORTH AVE
Mailing Address - Street 2:#480
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2425
Mailing Address - Country:US
Mailing Address - Phone:414-778-6670
Mailing Address - Fax:414-778-6672
Practice Address - Street 1:10400 W NORTH AVE
Practice Address - Street 2:#480
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2425
Practice Address - Country:US
Practice Address - Phone:414-778-6670
Practice Address - Fax:414-778-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21261700Medicaid
WIC01747OtherMEDICARE RAILROAD PIN
WIC01747OtherMEDICARE RAILROAD PIN