Provider Demographics
NPI:1639402365
Name:WISCONSIN HEART GROUP ASSOCIATES LLC
Entity Type:Organization
Organization Name:WISCONSIN HEART GROUP ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-754-3613
Mailing Address - Street 1:16650 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5920
Mailing Address - Country:US
Mailing Address - Phone:262-827-9200
Mailing Address - Fax:262-827-9858
Practice Address - Street 1:16650 W BLUEMOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5920
Practice Address - Country:US
Practice Address - Phone:262-827-9200
Practice Address - Fax:262-827-9858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN HEART GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-14
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207RC0000X, 207RI0011X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32678600Medicaid
WI000068590Medicare PIN
WI000001363Medicare PIN