Provider Demographics
NPI:1710107743
Name:BLUEMOUND SURGERY CENTER LTD
Entity Type:Organization
Organization Name:BLUEMOUND SURGERY CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:KORKOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-970-5600
Mailing Address - Street 1:N4W22370 BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1683
Mailing Address - Country:US
Mailing Address - Phone:262-970-5600
Mailing Address - Fax:262-970-5950
Practice Address - Street 1:N4W22370 BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1683
Practice Address - Country:US
Practice Address - Phone:262-970-5600
Practice Address - Fax:262-970-5950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000085943Medicare ID - Type Unspecified