Provider Demographics
NPI:1780677633
Name:WAUKESHA UROLOGY ASSOCIATES SC
Entity Type:Organization
Organization Name:WAUKESHA UROLOGY ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-548-3600
Mailing Address - Street 1:721 AMERICAN AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-548-3600
Mailing Address - Fax:262-548-3539
Practice Address - Street 1:721 AMERICAN AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-548-3600
Practice Address - Fax:262-548-3539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20043208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21258900Medicaid
WI21258900Medicaid