Provider Demographics
NPI:1518956309
Name:SHEBOYGAN UROLOGY SPECIALISTS, S.C.
Entity Type:Organization
Organization Name:SHEBOYGAN UROLOGY SPECIALISTS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-457-4858
Mailing Address - Street 1:1414 N TAYLOR DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1988
Mailing Address - Country:US
Mailing Address - Phone:920-457-4858
Mailing Address - Fax:920-457-3650
Practice Address - Street 1:1414 N TAYLOR DR
Practice Address - Street 2:SUITE 210
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1988
Practice Address - Country:US
Practice Address - Phone:920-457-4858
Practice Address - Fax:920-457-3650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21270800Medicaid
WI60230Medicare ID - Type Unspecified