Provider Demographics
NPI:1821700857
Name:PEDIATRIX MEDICAL GROUP OF WISCONSIN, SC
Entity Type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP OF WISCONSIN, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-243-3839
Mailing Address - Street 1:1301 CONCORD TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2843
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-738-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Multi-Specialty