Provider Demographics
NPI:1598700817
Name:KETTLE MORAINE ANESTHESIOLOGY INC
Entity Type:Organization
Organization Name:KETTLE MORAINE ANESTHESIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-334-5533
Mailing Address - Street 1:200 E WASHINGTON ST
Mailing Address - Street 2:P O BOX 8031
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5490
Mailing Address - Country:US
Mailing Address - Phone:866-313-0337
Mailing Address - Fax:920-739-0124
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-334-5533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21261200Medicaid
WI=========012OtherBLUE CROSS GROUP #
WI=========012OtherBLUE CROSS GROUP #
WI21215Medicare ID - Type UnspecifiedMEDICARE GROUP #