Provider Demographics
NPI:1659391076
Name:SOUTHERN WISCONSIN MEDICAL ASSOCIATES SC
Entity Type:Organization
Organization Name:SOUTHERN WISCONSIN MEDICAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GATTUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-884-3417
Mailing Address - Street 1:92 E STATE RD 59
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9001
Mailing Address - Country:US
Mailing Address - Phone:608-884-3417
Mailing Address - Fax:608-884-9347
Practice Address - Street 1:92 E STATE ROAD 59
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9001
Practice Address - Country:US
Practice Address - Phone:608-884-3417
Practice Address - Fax:608-884-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI218686972009OtherBLUE SHIELD
WI54145Medicare ID - Type Unspecified