Provider Demographics
NPI:1558443549
Name:GASTROENTEROLOGY SPECIALISTS SC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY SPECIALISTS SC
Other - Org Name:GASTROENTEROLOGY SPECIALISTS SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-6601
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 1080
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3689
Mailing Address - Country:US
Mailing Address - Phone:414-908-6601
Mailing Address - Fax:414-385-2980
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 212
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-544-8622
Practice Address - Fax:262-544-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32879000Medicaid
WI68085Medicare PIN
WI32879000Medicaid