Provider Demographics
NPI:1760413900
Name:NOVSAM, NED R (MD)
Entity Type:Individual
Prefix:
First Name:NED
Middle Name:R
Last Name:NOVSAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-8213
Mailing Address - Fax:262-656-8233
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-8213
Practice Address - Fax:262-656-8233
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI0030072208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31494300Medicaid
WI31494300Medicaid
WIE93887Medicare UPIN
WI000432143Medicare ID - Type Unspecified